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MANUAL 


OP 


Operative  Surgery 

BY 

JOSEPH  D.  BRYANT,  M.D. 

PROFESSOR    OF    INATOUCS    AND    CLINICAL    ETTRGERY,     AMD    ASSOCIATE    PROFESSOR 

OF  ORTHOPEDIC  SURGERY,  BELLEVUE  HOSPITAL  MEDICAL  COLLEGE;  VISITINQ 

SURGEON    TO    BELLEVUE    HOSPITAL,    AND    CONSULTING    SURGEON  TO 

THE    NEW  YORK    LUNATIC    ASYLUM    AND    THE    OUT-DOOB 

DEPARTMENT  OF  BELLEVUE  HOSPITAL 


WITH  ABOUT  800  ILLtlSTMTIONS 


Volume  I 


BERMINGHAM  &  COMPANY 

98  Union  Sqtjake,  East  I     20  King  William  St.,  Stband 

New  York  I  London 

1884 


Copyright,  1883,  by  Bkrmingham  &  Co, 


\'^I1  3  2, 
ft  ?^1. 

V.  \ 


TO 

STEPHEN  SMITH,  M.D., 

AND 

To  my  Preceptor, 

GEORGE  W.  AVERT,  M.D., 

THIS   VOLUME    IS    RESPECTFULLY    INSCRIBED, 

THOUGH  BUT  A  MEAGRE  RECOG^aTION  OF  THE 

MANY  KINDNESSES  SHOWN 

BY  THEU  TO 

THE  AUTHOR. 


PREFACE. 


The  frequent  request  on  the  part  of  those  whom  it  has 
been  my  pleasure  to  instruct  in  operative  surgery  during 
the  last  few  years,  to  make  a  book  based  somewhat  upon 
the  plan  employed  in  teaching  this  subject,  has  been  the 
principal  incentive  to  my  action.  The  field  of  operative 
surgery  is  too  well  cultivated  already  for  one  in  this  brief 
space  to  hope  to  do  more  than  to  aid  the  student  in  acquir- 
ing established  facts,  rather  than  to  add  to  the  art  itself. 
The  works  of  Ashhurst,  Gross,  Erichsen,  Holmes,  Packard, 
Smith,  Esmarch,  Stimson,  and  others,  have  been  fully  con- 
sulted, and  in  some  instances  their  language  has  been  em- 
ployed or  paraphrased.  The  illustrations,  which  are  nu- 
merous, have  been  in  most  instances  selected  from  the  works 
of  the  authors  just  mentioned,  although  a  considerable 
number  of  original  cuts  have  been  introduced.  The  author 
desires  to  acknowledge  the  aid  derived  from  the  sources 
mentioned,  and  trusts  that  the  reader  will  find  something 
to  commend  in  the  pages  that  are  to  follow.  The  operations 
peculiar  to  the  female,  and  the  eye  and  ear,  have  not  been 
considered,  since  they  are,  in  the  opinion  of  the  author,  en- 
titled to  a  far  more  extended  consideration  than  the  inten- 
tional scope  of  this  work  will  admit  of. 

J.  D.  Bryant. 

66  West  35TH  St.,  New  York,  December,  1883. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/manualofoperativ01brya 


OPERATIVE  SURGERY. 


Operative  surgery  treats  of  the  manual  procedures 
necessary  to  properly  accomplish  the  surgical  object  in 
view.  The  operation  to  be  done  is  the  execution  upon  the 
part  of  a  verdict  that  is,  or  should  be,  based  upon  surgical 
principles  and  laws  in  a  comparative  sense  of  legal  pro- 
ceedings in  the  Courts  of  Justice.  The  surgeon,  in  most 
instances,  however,  holds  the  threefold  position  of  judge, 
jury  and  executioner.  It  is,  therefore,  very  essential  for 
the  welfare  of  the  patient  that  he  properly  interpret  the 
surgical  laws  and  principles  relating  to  the  case,  in  order 
that  the  verdict  to  follow  may  be  just,  and  its  execution 
cast  no  opprobrium  upon  himself  or  his  profession.  To  be 
able  to  operate  understandingly  requires  not  only  a  thor- 
ough knowledge  of  the  principles  of  surgery,  but  a  fair 
knowledge  of  the  ways  and  means  of  accomplishing  the 
desired  purpose. 

It  is  not  enough  to  be  able  to  remove,  in  a  scientific  man- 
ner, an  offending  member  or  disease,  but  it  is  equally 
important  for  the  surgeon  to  so  prepare  the  patient  and 
himself  that  no  unanticipated  complication  can  occur  im- 
mediately prior  to,  during,  or  subsequent  to  the  operation. 

Regarding  the  principles  of  surgery  proper,  the  reader  is 
referred  to  the  many  works  upon  that  subject;  since  it  is 
not  the  intention  of  the  author  to  intrude  upon  this  depart- 
ment of  surgery,  except,  in  so  far  as  it  may  be  found  ex- 
pedient to  apply  them  to  the  immediate  safety  of  the 
patient  during  and  subsequent  to  the  operation. 

Prior  to  an  operation,  especially  if  it  be  one  of  any  mag- 
nitude, it  is  essential  that  the  following  facts  be  ascertained: 

First.  The  physical  condition  of  the  heart,  lungs,  kidneys, 
brain  and  great  vessels. 

Second.  If  there  be  an  acute  surgical  or  other  complica- 


18  OPERATIVE  SURGERY. 

tion  of  the  essential  organs  of  the  body,  joints,  serous 
cavities,  etc. 

Third.  If  the  patient  be  suffering  from  shock. 

Fourth,  If  the  patient  be  anaemic  or  scorbutic.  If  he 
has  syphilis,  phthisis,  epilepsy,  diabetes,  or  be  in  danger 
of  delirium  tremens. 

Fifth.  If  he  be  willing  and  ready  for  the  operation. 

Upon  the  healthful  condition  of  the  heart,  lungs,  brain, 
etc.,  may  depend  the  expediency  of  giving  an  anaesthetic, 
and  the  choice  between  them.  If  the  kidneys  be  diseased, 
it  may  be  inadvisable  to  operate  upon  the  urethra  or  blad' 
der,  or  even  to  give  an  anaesthetic;  if  the  great  vessels  be 
dilated  or  atheromatous,  much  discretion  must  be  employed 
in  its  selection  and  administration.  It  should  not  be  for- 
gotten, however,  that  the  mental  emotion  and  physical  suf' 
fering  attendant  upon  an  operation,  when  performed  with- 
out anaesthesia,  may  be  of  greater  moment  than  with  its 
use. 

If  the  injury  demanding  an  operation  be  recent,  and  the 
patient  be  suffering  from  a  severe  shock,  it  should  be  de- 
ferred until  reaction  is  established.  If  the  shock  be  out  of 
proportion  to  the  visible  injury,  a  careful  examination  of 
the  patient  must  be  made  to  ascertain  its  cause.  If  a  com- 
plicating injury  be  discovered,  which  of  itself  imperils  the 
life  of  the  patient,  all  idea  of  an  immediate  operation  must 
be  deferred.  These  thoughtful  attentions  lessen  the  right- 
eousness of  the  oft-repeated  satirical  expression,  "  The 
operation  was  successful,  but  the  patient  succumbed." 

If  the  patient  be  already  anaemic,  or  scorbutic,  the  loss 
of  blood  added  to  the  shock  of  the  operation  may  expose 
him  to  greater  dangers  than  if  the  operation  be  postponed. 
Unfortunately,  however,  in  a  majority  of  cases,  the  condi- 
tions calling  for  operative  interference  are  the  prime  fac- 
tors which  determine  the  degree  of  the  blood  changes,  and 
will  not,  of  themselves,  admit  of  any  delay. 

The  existence  of  syphilis,  phthisis,  diabetes,  etc.,  exert  a 
marked  influence  on  the  recovery,  and  their  importance 
must  not  be  underestimated  in  connection  with  this  fact. 
If  a  patient  be  addicted  to  the  continuous  use  of  intoxi- 
cating beverages,  and  worse  still,  if  he  receives  an  injury 
during  a  prolonged  debauch,  it  seriously  complicates  his 
case,  not  only  directly  from  the  previous  effects  upon  his 
bodily  vigor,  but  from  the  impending  danger  of  delirium 
tremens. 


GENERAL  CONSIDERATIONS.  I9 

It  is  not  necessary  to  the  successful  issue  of  an  operation 
that  the  patient  be  ready  and  willing  ;  yet,  if  such  a  fortu- 
nate combination  be  present,  it  will  weigh  heavily  in  favor 
of  ultimate  success.  It  is  prudent,  however,  that  he  should 
be  ready  in  a  legal  sense  ;  that  is,  that  his  consent  be 
gained. 

If  the  operation  be  a  dernier  ressori.^  he  should  be  given 
the  opportunity  of  adjusting  his  business  and  spiritual 
affairs.  If  they  be  prematurely  adjusted — if  such  be  possi- 
ble— the  knowledge  of  it,  and  the  quiet  of  mind  resulting 
therefrom,  will  become  valuable  aids  to  his  recovery. 

Season  of  the  Year. — Autumn  and  spring  are  the  best 
seasons  for  operating.  Still  it  is  not  always  practicable  to 
render  this  knowledge  available.  It  is  best  to  avoid,  as  far 
as  possible,  extremes  of  temperature.  Fair  weather  with 
an  ascending  barometer  is  more  propitious  than  the  re- 
verse. 

Time  of  day  should  be  such  as  to  secure  a  good  light 
until  the  completion  of  the  operation. 

The  surroundings  of  the  patient  subsequent  to  the  operation 
are  to  be  studied  with  great  care.  The  sick  room  should 
be  commodious  and  sunny,  and  when  possible  be  on  the  sec- 
ond floor  with  a  southern  exposure,  and  with  the  door  and 
windows  so  arranged  that  it  can  be  easily  ventilated  with- 
out exposure  to  improper  air-currents.  All  sewer-con- 
hected  wash-basins  or  other  receptacles  of  waste  must  be 
excluded  from  the  room.  The  plainer  the  walls  and  ceil- 
ings the  better  ;  for,  if  the  patient  become  delirious,  the  out- 
lines and  figures  of  modern  decorations  may  invite,  and 
form  the  basis  of  exciting  delusions.  It  is  better  at  all 
times,  for  hygienic  reasons,  that  the  room  be  as  plain  as 
possible,  and  that  all  unnecessary  articles  be  removed 
therefrom,  especially  when  it  is  to  be  reoccupied  for  a 
similar  purpose.  During  convalescence,  and  after  all 
dangers  from  septic  influences  are  passed,  objects  of 
interest  may  be  placed  upon  the  mantels  and  walls,  which 
can  be  varied  from  time  to  time  to  please  the  fancies  of  the 
patient. 

The  temperature  of  the  room  should  be  maintained  at 
about  70  degrees  Fahrenheit.  Pure  air  13  quite  as  essential 
to  a  rapid  recovery  as  good  food.  It  should  be  thoroughly 
ventilated  at  least  once  each  day;  this  can  be  readily  done 
by  opening  the  windows  and  doors,  thereby  creating  a 
through-and-through  current,  at  the  same  time  using  cau- 


20  OPERATIVE  SURGERY. 

tion  that  the  patient  be  protected  from  direct  draughts, 
and  be  well  covered  till  the  temperature  shall  have  resumed 
a  suitable  standard.  The  presence  of  flowers  and  other 
odoriferous  agents  are  not  to  be  encouraged  in  the  sick 
room,  although  they  may  exert  a  good  moral  influence,  in 
that  they  remind  the  patient  of  the  existence  of  sympathiz- 
ing friends  without.  It  must  always  be  made  as  cheerful 
as  possible,  consequently  all  annoyances  are  to  be  removed 
whenever  the  fancies  of  the  patient  indicate  their  presence. 

Place  for  a7i  Operation. — The  office  of  the  surgeon  is  not 
a  proper  place  to  do  operations  of  any  magnitude,  or 
even  those  requiring  the  use  of  an  anaesthetic,  because  the 
rest  and  quiet  that  should  follow  the  former  cannot  be  had 
if  the  patient  be  removed;  and,  moreover,  anaesthesia  is  often 
followed  by  persistent  nausea  and  vomiting,  and  not  infre- 
quently by  prolonged  noisy  delirium. 

Nursing. — All  who  require  the  services  of  a  nurse  should, 
if  possible,  secure  those  of  an  experienced  and  professional 
one.  The  well-intended  attentions  and  observations  of 
solicitous  friends  are  often  burdensome  to  the  patient 
and  misguiding  to  the  surgeon,  and  are  as  apt  to  be  con- 
trolled by  their  sympathy  for  the  patient  as  by  the  desire 
to  consult  the  express  wishes  of  the  medical  attendant.  It 
is  well  to  remember,  however,  that  a  discreet  friend  is  a  far 
better  attendant  than  a  garrulous  self-sufficient  nurse. 
The  attendant  who  proffers  his  views  and  experience  in 
the  sick-chamber,  hoping  thereby  to  honestly  impress  all 
present  with  his  worth,  is  as  detrimental  to  the  moral  at- 
mosphere of  the  room,  as  closed  windows  and  doors  are  to 
the  physical. 

Preparatory  Treatment. — This  should  be  directed  to  the 
improvement  of  the  patient's  general  condition,  also,  to  di- 
rectly combating  the  constitutional  diseases  which  may 
effect  the  ultimate  result. 

Diet. — Precisely  the  variety  and  amount  of  food  to  be 
given,  are  matters  which  must  be  determined  by  the  re- 
quirements of  the  individual  cases.  Milk,  eggs,  milk-punch, 
stimulants,  etc.,  are  stereotyped  articles,  the  usefulness  of 
which  is  well  established.  They  should  not,  in  any  in- 
stance, if  it  be  possible  to  avoid  it,  be  substituted  by  the 
traditional  beef  tea,  and  more  elaborate  chemical  extracts 
with  which  the  market  is  cloyed.  The  requirements  neces- 
sary to  secure  satisfactory  results  in  surgical  operations 
may  be  divided  into  the  essential  and  precautionary. 


GENERAL  CONSIDERATIONS.  2! 

The  essential  requirements  consist  of  such  implements, 
agents  and  information  as  are  necessary  to  the  proper  per- 
formance of  an  operation,  as  well  as  to  a  due  consideration 
of  the  result.  The  precautionary  are  those  which  are  useful 
in  the  various  emergencies  that  may  complicate  an  opera- 
tion; and  it  is  necessary,  if  they  are  to  be  of  practical 
utility,  that  they  should  be  at  hand  and  be  prepared  for 
immediate  use. 

ESSENTIAL   REQUIREMENTS. 

First.  A  knowledge  of  the  usual  result  of  the  operation 

about  to  be  performed. 

Second.  A  practical  knowledge  of  the  anatomy  of  the 
parts  involved  in  the  operation. 

Third.  Anaesthetics;  proper  means  of  administering,  and 
their  dangers. 

Fourth.  The  necessary  implements  and  a  knowledge  of 
their  use. 

Fifth.  Suitable  trays  to  hold  instruments. 

Sixth.  Operating  table,  sponges,  empty  vessels  and  an- 
tiseptic solutions. 

Seventh.  Agents  for  controlling  hemorrhage. 

Eighth.  Assistants  of  suitable  number  and  proficiency. 

Ninth.  A  patient  properly  prepared  for  the  procedure. 

Tenth.  Proper  materials  for  dressing  wounds  and  a 
knowledge  of  their  use. 

A  knowledge  of  the  usual  result  of  the  operatioti  about  to  be 
perfor?ned,  is  one  of  the  chief  factors  to  be  employed  to  de- 
termine its  propriety  ;  and  is,  therefore,  entitled  to  be  first 
considered.  This  knowledge  can  be  gained  from  only  two 
sources:  First,  the  personal  experience  of  the  operator  and 
of  those  from  whom  he  may  be  able  to  receive  an  opinion. 
Second,  the  recorded  experience  of  the  profession.  The 
first  implies  the  calling  of  a  consultation,  which  should 
always  be  done  whenever  a  doubt  exists  in  the  mind  of  the 
operator;  such  a  course  not  only  offers  to  the  patient  every 
available  chance,  but  in  unfortunate  results,  frequently 
serves  to  soothe  the  feelings  of  disappointment  experienced 
by  all  concerned.  If  a  consultation  be  not  feasible,  the 
surgeon  must  then  rely  upon  the  recorded  practical  knowl- 
edge of  the  profession. 

A  practical  understanding  of  the  anatomy  of  the  part  in- 
volved in  an  operation  is  always  essential  to  the  comfort  of 


22  OPERATIVE  SURGERY. 

the  operator,  and  often  to  the  safety  of  the  patient.  This 
knowledge  is  somewhat  difficult  to  obtain  and  is  always  of 
uncertain  tenure.  In  the  case  of  the  general  practitioner, 
it  consists  chiefly  of  that  which  can  be  gleaned  from  text- 
books and  anatomical  plates;  often  called,  "Flat  Anatomy," 
added  to  the  anatomical  knowledge  retained  since  gradu- 
ation. Those  who  reside  in  large  cities  can  avail  themselves 
of  the  ample  opportunities  afforded,  to  rehearse  important 
operations.  When  the  dead  can  be  made  generally  subser- 
vient to  the  welfare  of  the  living,  then  all  medical  men  can 
avail  themselves  of  the  only  means  of  becoming  fully  able 
to  surgically,  *'  Do  unto  others  as  they  would  be  done  by." 

Ancesthetics. — The  anaesthetics  in  established  use  are  ether, 
chloroform,  and  nitrous  oxide  or  laughing-gas.  The  first  is 
employed  far  more  in  surgery,  than  the  others  combined. 
The  chief  objections  to  its  use  are  its  pungency;  the  liability 
of  nausea  and  vomiting;  inflammability,  and  the  production 
of  cerebral  excitement. 

Its  disagreeable  pungency  can  be  lessened,  in  fact,  almost 
entirely  obviated,  by  allowing  a  good  volume  of  air  to  min- 
gle with  it  during  the  first  moments  of  its  administration. 
One  has  but  to  cover  his  own  face  with  the  well-charged 
ether  cone  in  common  use,  to  realize  the  sense  of  impending 
suffocation,  which  is  experienced  by  the  unwary  patient, 
whose  struggles  to  resist  it  are  often  violent,  and  suggest- 
ive of  the  belief  that,  upon  his  part,  the  struggle  is  for  life. 
Scenes  of  this  kind  should  always  be  avoided,  more  espe- 
cially when  the  patient  is  suffering  from  any  complications 
which  will  expose  him  to  an  additional  peril.  The  nausea 
and  vomiting  following,  are  not  of  sufficient  importance  to 
contra-indicate  its  use,  except  in  such  cases  as  it  would  be 
otherwise  objectionable. 

The  resultant  vomiting  is  chiefly  dangerous,  where  solid 
food  has  been  recently  taken,  often  causing  suffocation  by 
its  entering  the  larynx  and  trachea. 

Inflaminability. — This  is  only  to  be  regarded  while  operating 
in  the  presence  of  artificial  light,  or  with  the  actual  cautery. 
There  is,  however,  but  little  danger,  since  the  weight  of 
the  vapor  causes  it  to  create  a  downward  current,  thereby 
tending  to  remove  it  from  contact  with  the  igniting  agent. 
It  is  safer,  however,  for  all  concerned,  to  treat  it  on  such 
occasions  as  if  it  were  only  awaiting  the  slightest  oppor- 
tunity to  assert  its  power.  The  strong  cerebral  excitement 
which  often  precedes  complete  anaesthesia  may  be  due  to 


ANESTHETICS. 


23 


an  idiosyncrasy,  or  be  excited  by  surrounding  circumstances. 
The  patient  should  be  assured  that  no  harm  will  attend  its 
administration;  it  should  be  given  in  a  gentle  manner, 
slowly  in  the  beginning,  that  the  mucous  membranes  may 
not  suffer  too  great  irritation;  and  complete  quietude  on 
the  part  of  all  present  should  be  maintained,  since  talking 
often  serves  to  excite  the  inebriated  fancies,  and  forms  the 
basis  of  disorderly  actions.  The  handling  of  the  part  to  be 
operated  upon,  prior  to  complete  insensibility,  is  a  fertile 
source  of  annoyance,  and  is  often  suggestive  to  the  patient 
of  the  impending  operation.     These  are  precautions  which 


Fig.  I.— Chloroform  Inhaler.    (Esmarch.) 

should  be  observed  during  the  administration  of  all  anaes- 
thetics. 

Chloroform  is  more  dangerous  than  ether,  and  should 
not  be  used,  unless  the  contra-indications  to  the  use  of 
ether  are  exceedingly  strong.  Although  it  has  a  pleasant 
odor  and  is  devoid  of  pungency,  less  liable  to  induce  vom- 
iting and  cerebral  excitement,  non-inflammable  and 
quicker  of  action  than  ether,  yet  these  facts  w1:igh  but  lit- 
tle as  against  the  additional  dangers  incurred  by  its  use. 
At  the  present  time  its  application  as  an  anaesthetic  is 
almost  entirely  limited  to  children,  and  to  obstetrical  prac- 
tice. Chloroform  can  be  administered  by  pouring  a  few 
drops  on  a  napkin  which  is  held  at  a  short  distance  from 
the  nose,  or  by  the  agency  of  an  inhaler  figured  by  Esmarch 
(Fig.  i),  which  consists  simply  of  a  properly  shaped  wire 


24  OPERATIVE  SURGERY. 

framework,  covered  by  flannel  and  fastened  to  the  head. 
Nitrous  oxide  is  the  most  agreeable  and  least  dangerous  of 
the  anaesthetics  in  general  use.  Its  employment  is  limited 
to  operations  of  short  duration.  It  cannot  be  classed  as  a 
practical  anaesthetic,  since  its  expense,  the  cumbersome 
apparatus  for  administration,  and  transient  effects  unfit 
it  for  general  use.  It  is,  however,  often  employed  where 
the  presence  of  cardiac  or  other  organic  diseases  contra- 
indicate  the  use  of  ether  or  chloroform. 

Inhalers.-^Tht  variety  of  inhalers  for  administering  anaes- 
thetics is  large.  It  is  no  part  of  my  intention  to  discuss 
the  comparative  virtues  of  the  various  forms;  but  rather  to 
select  those  in  common  use,  so  that  the  general  practitioner 
residing  at  a  distance  from  the  basis  of  surgical  supplies, 
can  be  able  to  extemporize  at  least  one  of  the  many  which 
will  meet  the  pressing  indications. 

The  simplest  method  of  administering  any  anaesthetic, 
and  the  one  generally  employed  with  chloroform,  is  upon 
a  towel  or  napkin.  In  the  case  of  ether,  this  is  very  unsat- 
isfactory; inasmuch  as  it  involves  an  unnecessary  expendi- 
ture of  time  and  ether,  and  produces  a  less  satisfactory  an- 
aesthesia than  any  other  method.  There  are  other  perti- 
nent objections  to  it,  but  those  already  mentioned  are  of 
sufficient  weight  to  dismiss  its  further  consideration. 

The  simplest  form  of  ether  cone,  or  inhaler,  is  the  one 
that  has  been  for  a  long  time  in  common  use  in  many  of 
the  hospitals  of  this  city. 

The  method  of  its  construction  is 
simple  and  the  materials  employed 
are  always  accessible.  A  sheet  of 
paper  of  strong  texture,  or  three  or 
four  layers  of  an  ordinary  news- 
paper, two  feet  in  length  and  eigh- 
teen or  twenty  inches  in  width,  to- 
gether with  a  strong  piece  of  cloth, 
the  dimensions  of  which  shall  ex- 
ceed those  of  the  paper  two  or  three 
^''^-  *•  inches,  and    a  dozen  ordinary  pins, 

are  all  that  is  required  to  construct  it.  Place  the  cloth — a 
towel  is  usually  employed — and  the  paper  on  a  table,  with 
the  paper  uppermost;  fold  them  in  the  centre  of  their  long 
diameter,  which  will  bring  the  cloth  on  the  outer  surfaces 
and  the  paper  within.  Then  fold  them  in  the  short  diam- 
eter, the  length  of  the  fold  corresponding  to  the  distance 


ANESTHETICS.  2$ 

from  the  lower  border  of  the  symphysis  mentis  to  the  root 
of  the  nose  of  the  patient;  when  thus  folded,  pin  the  outer 
and  inner  extremities  firmly  through  the  whole  texture  of 
the  sides,  using  care  that  the  pins  be  so  placed  that  they 
will  not  stick  the  patient's  face,  or  the  hands  of  the  one  ad- 
ministering the  anaesthetic,  Several  pins  are  now  to  be 
passed  through  all  the  textures  in  various  situations  to  hold 
them  firmly  together.  One  end  of  this  tube  must  now  be 
closed,  which  is  easily  and  quickly  accomplished  by  turning 
inwards  its  borders,  and  securely  pinning  them  to  each 
other.  It  is  better  to  close  the  end  corresponding  to  the 
free  extremities  of  the  material,  thereby  giving  a  firmer 
basis  to  the  cone.  Into  the  top  of  the  cone  is  then  crowded 
a  good-sized  sponge,  or  a  piece  of  coarse-textured  cloth, 
always  observing  that  it  be  beyond  the  reach  of  the  nose 
and  face  of  the  patient  Absorbent  cotton  or  several  layers 
of  muslin  may  be  interposed  between  the  surfaces  of  the 
upper  end,  instead  of  their  being  closed  by  turning  and  pin- 
ning as  just  described.  If  this  material  be  now  confined 
in  position  by  means  of  pins  and  the  end  covered  with  a 
layer  of  thin  gauze,  the  ether  can  then  be  poured  upon  the 
interposed  material  and  administered  without  removing 
the  cone  from  the  face.  It  likewise  admits  the  requisite 
amount  of  air.  The  advantages  which  this  simple  affair 
possesses  over  the  permanent  and  more  expensive  ones,  are 
quite  numerous.  It  cannot  be  damaged  by  the  patient,  nor 
will  the  face  be  bruised  by  its  borders  during  his  struggles; 
it  is  a  temporary'  affair,  and  therefore  need  never  be  used  a 
second  time — a  fact  which  is  obviously  of  considerable  im- 
portance in  a  fastidious  and  hygienic  sense.  It  does  not, 
however,  admit  of  the  easy  regulation  of  the  amount  of 
ether  to  be  given,  or  the  amount  of  air  to  be  admitted;  it 
is  also  liable,  unless  care  be  used  in  replenishing  it  with 
ether,  to  permit  the  anaesthetic  to  flow  into  the  eyes  and 
upon  the  face  of  the  patient;  yet  these  are  objections  which 
can  be  easily  surmounted  by  a  requisite  amount  of  caution. 
The  amount  of  ether  required  with  this  apparatus  is  less 
than  if  a  napkin  be  used  alone,  while  it  exceeds  that  em- 
ployed in  the  more  perfect  inhalers. 

Allis'  inhaler,  which  consists  of  a  penetrated  metallic 
framework  for  the  support  of  cloth  partitions,  surrounded 
by  an  adjustable  leather  or  rubber  covering,  is  simple, 
efficient,  portable,  and  can  be  quite  easily  cleansed  (Figs.  3 
and  4).     Its  advantages,  briefly  stated,  are  the  following: 


26 


OPERATIVE  SURGERY. 


It  allows  a  free  admission  of  air  from  above,  which  becomes 
saturated  with  ether,  the  evaporating  surface  is  great, 
causing  thereby  a  rapid  vaporization,  which  hastens  an- 
aesthesia and  saves  ether.     The  ether  can  be  replenished 


Fig.  3. 


Allis'  Inhaler. 


Fig.  4. 


through  the  top,  which  obviates  the  necessity  of  removing 
the  inhaler  and  interrupting  the  administration. 

The  cloth  partitions  can  be   readily  changed  whenever 
propriety  and   cleanliness  demand   it.      The   inhalers    of 

Lente,  Squibb,  Noyes,  Chis- 
holm,  and  others,  are  all 
serviceable,  and  whoever 
possesses  either  of  them 
can,  so  far  as  the  apparatus 
is  concerned,  administer 
ether  with  safety.  It  is  not 
necessary  to  the  safety  of 
the  patient  that  either  of 
them  be  employed.  It  is, 
however,  necessary  to  the 
safety  of  the  patient,  no 
matter  which  one  be  em- 
ployed, that  the  giver  of  the 
anaesthetic  shall  rely  more 
upon  his  knowledge  of  the 
principles  governing  its  administration  than  upon  the  mech- 
anism of  the  apparatus.  With  a  proper  knowledge  of  these 
principles,  it  matters  but  little  whether  one  or  another 
form  of  inhaler  be  used. 


Fig.  s. — Lentk's  Inhaler. 


ANESTHETICS. 


27 


Lenie's  Inhaler  (Fig.  5). — The  construction  of  this  appa- 
ratus is  so  simple  that  space  is  not  necessary  to  describe 
it.  The  modified  inhaler  has  additional  advantages,  how- 
ever.     Either  answers  the  purpose  admirably. 

Squibb' s  Inhaler  (Fig.  6). — This  consists  of  an  hour-glass- 
shaped  muslin  bag,  one  end  of  which  is  cut  off  to  fit  the 
face  of  the  patient.  The  narrow  portion  is  made  to  receive 
a  tin  tube  several  inches  in  length  and  two  in  diameter ; 
the  round  end  serves  the  purpose  of  an  air-chamber. 
When  the  bag  is  to  be  used  it  should  be  wetted  with 
water  and  thoroughly  squeezed,  to  render  it  only  partially 
pervious  to  the  passage  of  air  or  other  vapor.  Into  the  tin 
tube  a  piece  of  flannel  and  blotting-paper  rolled  together, 
each  about  six  inches  wide  and  eighteen  inches  long,  are 
thrust,  after  which  they  are   saturated  with  ether;  or  it 


Fig.  6.— Squibb's  Inhaler. 

may  be  done  before  the  introduction.  The  open  end  of 
the  apparatus  is  then  placed  over  the  mouth  and  nose  of 
the  patient  and  the  administration  commenced.  One  to 
two  and  a  half  ounces  are  quite  enough  to  properly 
anaesthetize  the  patient. 

Noyes'  Inhaler  (Fig.  7). — This  apparatus  is  simple  of  con- 
struction. It  consists  of  a  flexible  air-cham.ber  at  one  end 
and  a  face  piece  at  the  other.  Between  the  two  is  a  small 
tin  chamber  to  contain  the  ether.  The  bag  or  air-chamber 
is  perforated  by  a  small  hole,  which  allows  the  entrance  of 
a  sufficient  amount  of  air,  which  enters  the  lungs  along 
with  the  ether  at  each  effort  of  inspiration.  The  amount  of 
ether  with  this  is  about  the  same  as  with  the  preceding. 

The  amount  of  ether  required  to  produce  insensibility  de- 
pends upon  several  conditions,  the  most  important  of  which 
are,  the  susceptibility  of  the  patient,  the  manner  of  admin- 
istering, and  the  purity  of  the  anaesthetic.     Some  persons 


2S 


OPERATIVE   SURGERY. 


can  be  completely  anaesthetized  by  an  ounce,  and  even 
less,  if  it  be  not  wasted;  on  the  other  hand,  those  are  occa- 
sionally met  with  who  "  take  ether  badly,"  and  cannot  be 
rendered   quiet  unless  a  large  amount  be  given;  rarely,  a 


Fig.  7. — NoYES'  Inhalkr. 

case  is  encountered  which  will  not  yield  to  its  influence,  and 
the  surgeon  is  forced  to  desist,  from  fear  of  destroying  the 
patient.  It  is  not  prudent  to  determine  in  advance  the  defi- 
nite amount  that  will  be  used,  except  possibly  in  some  pe- 
culiar cases.  Anaesthesia  is  never  to  be  attempted  unless 
the  surgeon  can  be  certain  he  has  a  sufficient  amount  to 


Fig.  8. — Chisholm's  Inhaler. 


complete  the  operation,  for  nothing  can  be  more  humiliat- 
ing than  to  be  obliged  to  discontinue  an  operation  for  the 
purpose  of  procuring  additional  ether.  It  is  not  politic  to 
begin  an  operation  that  requires  much  time  and  care,  with- 
out at  least  one  pound  of  ether  be  at  hand. 


ANESTHETICS.  2g 

Purity  of  the  Anesthetic. — It  is  important  that  the  anaes- 
thetic be  pure,  in  order  that  the  amount  taken  may  be  suita- 
bly judged,  and  a  proper  interpretation  placed  upon  the 
effect  produced.  Those  manufactured  by  Squibb,  of  Brook- 
lyn, are  generally  considered  to  be  of  a  superior  quality. 

Dangers  from  the  Use  of  Ether. — The  dangers  attending 
the  use  of  anaesthetics  may  be  reduced  to  a  minimum,  pro- 
vided proper  attention  be  given  to  the  physical  conditions 
recognized  as  contra-indicatingor  requiring  caution  in  their 
use,  together  with  a  display  of  ordinary  care  in  administer- 
ing. Before  giving  it,  the  heart,  lungs,  brain,  and  kidney 
vessels,  etc.,  should  be  interrogated,  even  though  there  be 
no  apparent  evidences  of  disease.  If  they  have  undergone 
organic  changes,  or,  if  the  patient  have  laryngeal  obstruc- 
tion from  any  cause,  bronchitis,  or  be  pregnant,  the  great- 
est caution  must  be  employed  in  the  administration  even 
if  it  be  given  at  all.  The  degree  of  the  disease,  and  the 
condition  of  the  patient  dependent  thereon,  together  with 
the  necessity  of  an  immediate  operation  and  its  severity, 
must  determine  the  advisability  of  its  use.  If  the  patient 
have  advanced  heart  and  kidney  disease,  phthisis,  or 
aneurism,  it  is  better  to  use  nitrous  oxide;  chloroform,  even, 
has  been  used  under  such  circumstances  instead  of  ether, 
on  account  of  its  causing  less  excitement  and  vomiting. 
The  danger  from  a  full  stomach  is  great,  especially  if  the 
ingesta  be  solid;  since,  if  vomiting  occur,  the  food  may  be 
sucked  into  the  larynx  and  trachea,  causing  death  by  suffo- 
cation ;  moreover,  nausea  and  vomiting  are  more  frequent 
and  persistent  when  the  stomach  is  partially  filled  with 
food.  It  is  impracticable  to  lay  down  all  the  important  re- 
lations existing  between  the  use  of  an  anaesthetic  and  the 
various  complications  that  may  exist  as  contra-indications. 
The  surgeon  must  be  largely  controlled  by  the  circumstances 
surrounding  the  individual  case.  If  it  be  determined  toad- 
minister  ether  or  chloroform  to  a  patient  suffering  from  a  de- 
bilitated heart,  the  latter's  action  must  be  strengthened  by 
the  administration  of  digitalis  some  days  prior  to  the  opera- 
tion, as  well  as  by  stimulants  during  it.  If  the  patient  have 
laryngeal  obstruction,  from  spasm  of  the  glottis  or  other 
causes,  the  pungency  of  the  ether,  and  spasm  of  the  respira- 
tory muscles,  when  added  to  the  already  lessened  area  of 
the  respiratory  chink,  and  the  diminished  aeration  of  the 
blood  resulting  therefrom,  may  be  often  sufficient  to  produce 
rapid  unconsciousness  and  impending  death  from  asphyxia. 


30  OPERATIVE   SURGERY. 

In  my  opinion,  chloroform  is  the  better  anaesthetic  under 
such  circumstances. 

How  to  Prepare  a  Patient  for  Anasthesia. — First.  Inform 
yourself  of  the  state  of  the  brain,  heart,  lungs,  kidneys, 
vessels,  etc.;  if  disease  be  found,  inform  the  patient  or  the 
friends  of  the  additional  dangers  incurred. 

Second.  Count  the  pulse  and  respiration,  noting  the 
character  of  each,  and  making  due  allowance  for  the  excite- 
ment dependent  upon  surrounding  circumstances.  These 
observations  will  be  far  more  valuable  if  they  have  been 
taken  some  time  prior  to  the  immediate  operation. 

Third.  See  that  no  solid  food  has  been  taken  for  at  least 
six  to  eight  hours  before;  if  so,  evacuate  the  stomach  by 
means  of  a  simple  and  rapid  emetic.  The  practical  way  of 
having  the  stomach  in  a  proper  condition  is  to  omit  the 
meal  preceding  the  operation.  If  the  time  be  too  long  for 
this,  a  glass  or  two  of  milk  three  or  four  hours  before  will 
meet  the  indications. 

Fourth.  Remove  all  false  teeth  from  the  mouth,  or 
whatever  else  might  fall  into  the  larynx. 

Fifth.  Loosen  all  constricting  bands  which  surround 
the  abdomen,  chest,  and  throat. 

Sixth.  Cause  the  evacuation  of  the  contents  of  the  blad- 
der and  rectum;  this  will  often  prevent  the  soiling  of  the 
clothes  and  patient. 

Seventh.  Place  the  patient  upon  the  back  with  the  head 
and  shoulders  slightly  raised;  neck  not  bent. 

Eighth.  If  the  patient  have  a  beard,  wet  it  to  prevent  the 
rapid  escape  of  the  ether  through  it. 

Ninth.  Adjust  windows  and  doors  to  admit  fresh  air, 
without  exposing  the  patient  to  a  draught. 

Tenth.  Disarm  the  patient  of  all  fears  of  danger  attend- 
ing its  use. 

The  one  who  is  to  administer  the  anaesthetic  should  have 
at  his  convenience  a  basin,  towel,  and  a  tenaculum  or  for- 
ceps. The  first  for  the  reception  of  the  dejections  from 
the  stomach  ;  the  towel  to  remove  the  saliva,  etc.,  from  the 
mouth  and  face;  the  tenaculum  or  forceps,  to  pull  forward 
the  tongue  if  it  fall  backward  over  the  glottis. 

It  is  recommended,  and  with  much  force,  to  administer 
hypodermically  or  otherwise  a  dose  of  morphia  an  hour 
or  so  before  anaesthesia  is  to  be  commenced.  It  quiets  the 
nervous  excitement  of  the  patient,  reduces  the  amount  of 
ether  otherwise  necessary,  and  prolongs  its  effect;  lessens 


ANESTHETICS. 


31 


the  tendency  to  nausea  and  vomiting,  and  diminishes  shock. 
Moderate  inebriation  has  been  produced  immediately  in 
advance  of  an  operation  by  giving  brandy  or  whisky,  and 
for  substantially  the  same  reasons. 

Method  of  Adininistering  Ether. — Commence  by  pouring  a 
small  amount,  an  ounce  or  so,  into  or  upon  the  inhaler, 
and  adjust  it  so  that  a  good  volume  of  air  shall  mingle  with 
the  ether,  for  the  first  fe\'  moments  of  the  administration. 
After  the  sense  of  pungency  has  somewhat  subsided,  the  pa- 
tient should  be  told  to  "cough,"  "breathe  deeply,"  at  the 
same  time  the  fresh  air  is  to  be  quite  rapidly  excluded.  The 
patient  soon  becomes  oblivious,  and  may  be  fully  anaesthe- 


FiG.  g. — Drawing  the  Tongue  Forward.    (Esmarch.) 

tized  without  further  trouble.  This  is  recognized  by  the 
insensibility  of  the  conjunctiva,  or,  what  is  better,  a  relaxed 
muscular  system,  which  is  ascertained  by  noting  the  ab- 
sence of  any  resistance  to  flexing  or  extending  the  extremi- 
ties. If  an  extremity  be  raised  from  the  bed,  it  will  fall 
directly  downward  and  lie  motionless.  Stertorous  breath- 
ing is  likewise  a  concomitant  of  complete  anaesthesia.  More 
often,  however,  the  patient  will  be  seen  to  pass  through  the 
three  distinct  stages  of  anaesthesia,  which  will  vary  in  their 
length  and  manifestations,  according  to  his  peculiarities. 
The  attention  of  the  giver  of  the  anaesthetic  should  always 
be  directed  to  the  character  of  the  respiration  and  pulse, 


32 


OPERATIVE  SURGERY. 


the  color  of  the  surface  and  its  temperature.  The  respira- 
tion is  often  temporarily  stopped  or  impeded  by  the  tonic 
stage,  causing  marked  cyanosis.  This  is  quite  readily  re- 
lieved by  making  sudden  and  forcible  pressure  in  the  epi- 
gastrium, or  slapping  the  chest  with  the  naked  hand  or  a 
wet  towel.  The  respiration  may  be  obstructed  or  prevented, 
at  any  period  of  anaesthesia,  by  foreign  bodies  in  the  larynx 
and  trachea;  such  as  false  teeth,  vomited  matter,  etc.  In 
complications  of  this  character  the  obstructing  agent  must 
be  removed  immediately  or  death  will  ensue,  unless  tracheot- 
omy be  performed.  The  glottis  may  become  stopped  by 
the  falling  backwards  of  the  tongue;  this  usually  occurs 
during  the  stage  of  complete  anaesthesia,  and  is  to  be  in- 


FiG.  10.— Pushing  the  Jaw  Forward.    (Esmarch.) 

stantly  remedied  by  drawing  the  tongue  forward  by  the  aid 
of  a  tenaculum  or  dry  towel  or  forceps. 

If  the  jaw  be  pressed  forward  during  the  administration 
of  the  anaesthetic,  by  the  one  giving  it  (Fig.  lo),  the  muscular 
attachments  of  the  base  of  the  tongue  are  separated,  and 
its  base  depressed  and  drawn  forward. 

The  treatment  for  the  relief  of  poisoning,  due  either  to  an 
overdose  of  ether  or  chloroform,  is  substantially  the  same. 
Successful  treatment  will  depend  not  only  upon  the  pres- 
ence of  mind  of  the  surgeon,  but  upon  the  precautionary 
preparations  which  have  been  made  for  such  a  contingency, 
as  well  as  the  rapidity  and  force  with  which  the  remedies 
are  applied. 


ANESTHETICS.  33 

The  anaesthetic  must  be  stopped  at  once;  the  head  low- 
ered and  the  tongue  pulled  forward;  windows  and  doors 
opened  to  admit  fresh  air;  artificial  respiration  (Figs.  11  and 
12);  flagellation  of  the  face  and  chest  by  towels  wet  with 
cold  water;  hypodermic  injections  of  brandy,  whisky,  or 
ammonia;  inhalation  of  nitrite  of  amyl,  and  the  use  of  elec- 
tricity. It  is  not  intended  that  these  remedies  shall  be 
used  in  the  order  mentioned;  but  the  surgeon  and  his  as- 


FiG.  II. — Artificial  Respiration— First  Movement.    (Esmarch.) 

sistants  will  find  their  time  and  thoughts  occupied  in  carry- 
ing them  into  execution — such  of  them  as  may  admit  of 
instant  application.  Under  no  consideration  must  the 
efforts  of  resuscitation  be  allowed  to  flag,  or  be  stopped, 
until  every  hope  of  saving  the  life  has  some  time  since 
passed.* 

*In  performing  artificial  respiration  the  movements  should  be  done 
slowly  and  with  a  regularity  similar  to   the  normal  act  of  respiration. 


34 


OPERATIVE  SURGERY. 


Fig.  19. — Artificial  Respiration — Second  Movement.    (Esmarch.) 

Local  AncBsthesia. — Although  there  are  numerous  agents  in 
use  for  this  purpose,  ether  possesses  the  greatest  number 
of  practical  advantages.     The  following  instrument  (Fig. 


Fig.  13.— Richardson's  Spray. 


To  move  the  arms  upward  and  downward  with  the  rapidity  of  a  pump- 
handle  is  irrational  and  inopperative  ;  yet  under  the  influence  of  ex* 
citing  surroundings  such  a  manner  is  not  infrequently  to  be  seen, 


INSTRUMENTS  IN  GENERAL  USE. 


35 


13)  is  the  one  commonly  used  for  purposes  of  local  anaes- 
thesia, and  is  employed  in  those  minor  operations  which 
can  be  quickly  done.  The  pain  that  follows  the  return  of 
sensibility  to  the  benumbed  parts  is  often  more  severe  and 
prolonged,  than  the  immediate  suffering  from  the  operation 
without  its  use.  The  tissues  should  not  be  frozen,  but 
be  numbed;  since  to  freeze  them  increases  the  pain  and 
retards  repair. 

INSTRUMENTS   NECESSARY    FOR   THE   PERFORMANCE   OF 
OPERATIONS. 

The  instruments  necessary  for  the  performance  of  an 
operation  must,  of  necessity,  be  regulated  by  its  magnitude 
and  nature.  They  can,  however, 
for  the  sake  of  brevity,  be  divided 
into  those  in  general  use  and  those 
for  special  purposes.  The  ones  in 
general  use  include  scalpels  and  1^ 
bistouries  of  various  forms  (Fig. 
14),  thumb  forceps,  groved  directors, 
and  scissors.  Those  for  special  pur- 
poses are  used  in  performing  the 
operations  which,  in  most  instances, 
caused  their  creation.  These  will 
be  considered  in  connection  with 
the  operations  to  which  they  are 
particularly  adapted. 

Method  of  holding  the  Scalpel. — 
Three  positions  are  commonly  rec- 
ommended, each  of  which  is  sub- 
divided into  two.  The  basis  of  the 
positions  rests  upon  the  manner  of 
holding  the  ordinary  table  knife,  the 
pen,  and  violin  bow. 

Figs.  15  and  16  represent  the  subdivisions  of  the  first 


Fig.  14. 
scalfkls  and  bistouries. 


Fis.  15. 


36 


OPERATIVE  SURGERY. 


Fig.  i6. 


Fig.  I 


position;  they  indicate  that  force  or  firmness  are  desired. 
Figs.  17  and   18  represent  the  subdivisions  of  the  secon4 


INSTRUMENTS. 


37 


positions;  these  are  taken  when  quick,  delicate  and  precise 
movements  are  required.  Figs.  19  and  20  are  the  subdi- 
visions of  the  third  position,  and  are  employed  when 
caution  is  used  in  conjunction  with  delicacy  in  cutting. 
.  These  positions  are  more  essential  to  graceful,  than  to 
successful  operating. 

Thumb  forceps  (Fig.  21)  are  used  in  connection  with  the 


Figs.  19  and  20. 

scalpel  or  scissors.  They  are  employed  to  pick  up  tissues, 
like  the  fascia,  etc.,  which  are  to  be  incised  at  the  point 
grasped  for  the  purpose  of  inserting  the  grooved  director. 
The  scalpel  or  bistoury  should  beheld  at  nearly  an  angle  to 
the  forceps  when  the  incision  is  made,  especially  when  im- 
portant structures  lie  immediately  beneath  (Fig.  22). 

The  grooved  director  (Fig.  23)  is  used  to  raise  the  tissues 


Fig.  21. — Thumb  Forceps. 

which  are  to  be  divided  with  caution.  It  should  be  five  or 
six  inches  in  length,  depending  upon  the  length  of  the  in- 
cision and  the  depth  of  the  wound  into  which  it  is  to  be 
inserted;  flexible,  with  a  broad  extremity  to  grasp,  and  a 
pocket  at  the  end  of  the  groove  to  arrest  the  point  of  the 
knife  or  scissors.  It  should  not  be  pushed  beyond  the  ex- 
tremities of  the  external  incision  because  of  the  danger 
of  making  pockets  in  the  soft  parts,  which  will  impede 
drainage.     The  tissues  raised  upon  the  director  must  not 


38  OPERATIVE   SURGERY. 

be  divided  beyond  the  angles  of  the  external  incision. 
Care  should  be  taken  when  the  director  is  passed  between 
a  serous  membrane  and  its  superimposed  fascia  that  the 
membrane  does  not  fold  over  the  advancing  extremity, 
thereby  causing  it  to  be  punctured  or  divided  by  the  knife 
or  scissors. 

The   Scissors. — They   are   used    as    a   substitute    for   the 
scalpel  in  incisions  of  great  depth,  JBmbined  with  limited 


Fig.  as.— Nicking  Fascia. 

space  and  a  necessity  for  caution.  Less  hemorrhage  fol- 
lows their  use  than  from  the  scalpel,  owing  to  the  crushing 
nature  of  their  force.  They  should  be  more  or  less  angular, 
to  accommodate  them  to  the  depth  of  the  operation  wound 
(Figs.  24  and  24^?). 

Incisions.— The  varieties  of  incisions  are  numerous,  and 
are  named  from  the  shape  which  they  take.  The  outlines 
of  incisions  are  controlled  very  largely  by  the  underlying 
anatomy;  the  desire  to  secure  good  drainage,  and  to  avoid 
disfiguring  the  patient.  There  is  a  greater  danger  of  mak- 
ing an  incision  too  short  than  too  long;  and  of  the  two,  the 


INSTRUMENTS. 


39 


former  is  the  greater  evil.  A  long,  deep,  clean-cut  incision 
will  drain  better  and  heal  more  quickly  than  a  short  deep 
one,  bounded  by  tissues  which  have  been  disturbed  by  the 
efforts  to  accomplish  a  definite  purpose  within  a  too  lim- 
ited space.  The  various  forms  of  incisions  will 
appear  in  connection  with  the  operations  to  which 
they  are  applicable. 


Fig.  23. 


Fig. 


Fig.  24a. 


Instruments  should  be  Plain. — All  instruments  associated 
with  surgery  should,  when  practicable,  be  constructed  in  a 
plain  and  substantial  manner.  The  handles  and  shanks  of 
the  knives  should  be  smooth  and  closely  fitted.  The  in- 
equalities   of    instruments    tend    to    catch    impurities,  and 


40  OPERATIVE  SURGERY. 

should  never  be  tolerated  when  they  but  serve  to  embellish 
the  implement. 

Receptacle  for  Instruments. — It  is  better  that  all  instruments 
be  made  aseptic  before  they  are  used;  for  this  purpose,  a 
shallow  tray  of  suitable  dimensions  should  be  filled  with  an 
aseptic  fluid,  and  the  instruments  be  immersed  therein  for 
an  hour  or  two  before  they  are  used.  This  tray,  with  the 
contents,  should  be  placed  at  a  convenient  distance,  in 
order  that  the  instruments  may  be  taken  directly  from  it 
when  needed.  If  they  are  to  be  again  required,  they  should 
be  returned  to  the  tray  as  soon  as  used. 

Operating  Table. — The  patient  should  always  be  placed 
upon  a  genuine,  or  an  extemporized  table,  of  sufficient 
height  to  suit  the  convenience  of  the  surgeon.  To  operate 
upon  abed  or  lounge,  as  is  often  done,  not  only  cripples  the 
resources  of  the  surgeon,  but  robs  him,  too  often,  of  a  suit- 
able light,  to  say  nothing  of  the  soiling  of  the  bedding. 
There  are  numerous  styles  of  operating  tables,  many  of 
which  are  of  very  ingenious  construction;  they  are,  how- 
ever, much  better  suited  for  hospital  than  private  practice. 
The  ordinary  table,  covered  by  an  old  quilt  and  rubber 
cloth,  will  meet  all  common  indications. 

Empty  Vessels. — There  should  always  be  a  good  supply  of 
empty  pails  and  basins  to  receive  the  waste-water,  soiled 
linen,  amputated  parts,  etc.  At  least  one  empty  basin 
should  be  provided  to  receive  the  soiled  sponges,  otherwise 
they  may  fall  upon  the  floor  or  table,  and  be  stepped  or 
pressed  upon,  or  lost.  A  pail  or  two  each  of  water,  hot  and 
cold,  should  be  provided  to  wash  the  sponges  during, 
and  the  hands  and  instruments  after,  the  operation;  for  the 
latter  purpose  hot  water  is  better. 

Clean  Toivels  and  Old  Linen. — An  abundance  of  these  should 
be  at  hand,  and  for  obvious  reasons.  However,  if  the  opera- 
tion is  being  conducted  on  strict  antiseptic  principles,  they 
must  not  be  used  until  after  the  wound  is  dressed;  unless 
.they  be,  at  first,  saturated  with  the  antiseptic  solution. 

Antiseptic  solutions  must  be  abundantly  provided  and  be 
used  in  the  place  of  water,  by  all  who  are  obliged  to  handle 
the  undressed  wound,  or  the  instruments  which  are  to  be 
brought  in  contact  with  it.  Carbolic  acid  is  more  often 
used  than  all  the  others  combined.  It  is  cheap,  efficient, 
and  easily  obtained.  Two  solutions  are  commonly  em- 
ployed: one,  called  the  weaker,  and  the  other  the  stronger 


ANTISEPTIC   SOLUTIONS.  4I 

solution.     The  latter  can  be  made  in  the  following  man- 
ner: 

Carbolic  acid  crystals i  part. 

Alcohol I     " 

Water 20  parts. 

This  is  employed  to  wash  the  wound  before  and  subse- 
quent to  an  operation.  It  is  used  with  the  spray,  and  to 
purify  all  the  instruments  ;  it  may  be  used  to  wash  the 
hands  prior  to  operating,  but  this  strength  is  objectionable, 
since  it  often  benumbs  the  keen  sense  of  touch  and  other- 
wise causes  them  to  feel  disagreeable.  The  weaker  solu- 
tion is  made  by  taking — 

Carbolic  acid  crystals i  part. 

Alcohol I     " 

Water 40  parts. 

This  is  employed  for  general  purposes  of  cleanliness,  and 
has,  therefore,  a  somewhat  more  extended  range  of  use- 
fulness. 

Carbolic  acid  is  often  combined  with  oleaginous  sub- 
stances in  the  proportions  of  one  to  five  or  ten.  Ligatures 
may  be  soaked  in  these  preparations,  and  lint  be  saturated 
with  them  and  applied  directly  to  the  granulating  surfaces. 
The  objections  to  carbolic  acid  are  its  offensive  odor,  and 
liability  to  produce  poisoning.  The  former  can  be  tol- 
erated, while  the  latter  can  be  prevented  in  nearly  all  in- 
stances by  not  allowing  the  strong  solution  to  become  con- 
fined within  the  tissues.  Solutions  of  the  chloride  of  zinc 
(1-15);  sulpho-carbolate  of  zinc  (1-80);  bichloride  of  mer- 
cury (1-2000),  and  a  saturated  solution  of  boracic  acid, 
pure  or  diluted  (1-2);  sulphurous  acid;  a  saturated  solu- 
tion of  iodoform  and  ether,  are  employed  as  washes,  or 
modified  applications  for  wounded  surfaces.  The  objec- 
tionable odor  of  iodoform  may  be  improved  by  adding  to 
it  one  tenth  its  weight  of  thymol.  Tonka  bean,  or  balsam 
of  Peru. 

Sponges.— The  variety  known  as  "surgeon's  sponges"  are 
the  best,  although  expensive.  The  larger  sponges  of  a 
proper  texture  can  be  cut  into  pieces  of  a  suitable  size, 
thoroughly  cleansed  and  disinfected,  when  they  will  answer 
all  purposes.  No  sponge  of  whatever  quality  should  be 
used  till   it  has  been   thoroughly   deprived  of  all  foreinn 


4Z  OPERATIVE   SURGERY. 

matters  and  disinfected.  It  is  a  good  practice  to  select 
and  cleanse  a  number  of  sponges,  and  keep  them  in  a  closed 
jar  containing  a  strong  solution  of  carbolic  acid,  until 
needed.  They  should  not  be  repeatedly  used;  it  is  far 
more  consistent  with  careful  surgery  to  get  a  new  supply 
in  each  individual  case,  than  to  use  them,  even  a  second 
time,  under  the  most  favorable  circumstances. 

Agents  for  controlling  Heniorrhage. — The  agents  that  arrest 
hemorrhage  are  multifarious  and  suited  to  all  of  its 
phases.  They  may  be  divided  into  the  natural  and  arti- 
ficial, each  of  which  may  be  subdivided  into  the  temporary 
and  permanent.  A  natural  agent  is  one  interposed  by 
nature;  one  which  results  as  a  natural  consequence,  from 
an  interference  with  the  inherent  tendencies  or  endowments 
of  the  vessels  and  blood.  The  principal  temporary  natural 
hemostatics  consist  of  the  contraction  and  retraction  of  the 
inner  coat  of  a  divided  or  ligatured  vessel,  accompanied  by 
the  formation  of  a  blood  clot  within  it.  The  contraction 
and  retraction,  if  perfect,  require  that  the  coats  of  the  ves- 
sels be  not  diseased;  and  that  they  be  properly  constricted 
by  the  ligature,  or  other  force.  The  formation  of  the  in- 
ternal clot  requires  that  a  suitable  distance,  depending 
upon  the  size  of  the  vessel,  shall  exist  between  the  ligature 
and  the  collateral  branches;  also,  that  the  coats  of  the  ves- 
sel be  not  greatly  diseased. 

These  points  are  of  importance  in  determining  the  site 
and  feasibility  of  an  operation.  The  permanent  natural 
agent  is  the  organization  and  contraction  of  the  clot;  there- 
by completely  occluding  the  artery;  this  result  will  depend 
largely  upon  the  condition  of  the  coats  of  the  vessel,  and 
has  a  very  important  bearing  upon  the  possibility  of  that 
much  to  be  dreaded  sequel  of  an  operation,  secondary 
hemorrhage. 

Artificial  Heniastatics. — This  class  is  always  temporary. 
The  following. are  the  well-recognized  ones  in  constant  use: 
Cold,  styptics,  position  of  injured  part,  bandages  of  vari- 
ous forms,  digital  and  instrumental  pressure;  also,  pressure 
by  a  simple  or  graduated  compress;  acupressure,  torsion, 
forceps,  serresfines,  compressors,  cautery,  etc.;  finally,  and 
best  of  all,  the  ligature. 

Styptics,  such  as  liquor  ferri  sub-sulphatis,  tannin,  etc., 
are  frequently  employed  to  check  oozing;  hot  water  being 
especially  indicated  when  the  patient  is  debilitated,  or  suf- 
fering from   severe  shocks.     Liquor  ferri  sub-sulphatis  is 


BANDAGES.  43 

decidedly  objectionable  where  union  by  first  intention  is 
desired,  but  is  very  serviceable  when  an  antiseptic  styptic 
is  required. 

Position. — Elevation  or  flexion  of  a  limb  serves  to  impede 
its  circulation,  and  thereby  lessens  the  tendency  to  hem- 
orrhage. The  reverse  of  this  principle  directs  us  to  lower 
the  head  in  prostration  from  loss  of  blood. 

Bandages. — These  may  be  divided  into  two  distinct 
classes,  the  inelastic  and  elastic.  The  inelastic,  or  ordinary 
roller,  can  be  used  to  check  capillary  and  venous  oozing  by 
applying  it  firmly  over  the  bleeding  part. 

Elastic  Bandage — of  which  Esmarch  is  the  projector — is 
made  of  elastic  webbing  the  width  of  an  ordinary  roller, 


Fig.  25. 

and  of  sufficient  length  to  meet  the  requirements  (Fig.  25). 
It  is  to  be  applied  in  a  spiral  manner  to  the  limb,  firmly  from 
the  distal  extremity  upward  (Fig.  26)  to  a  good  distance 
above  the  point  to  be  operated  upon,  where  it  is  supple- 
Ijiented  by  a  rubber  cord,  or  strap,  passed  firmly  around  the 
limb  at  this  point,  and  fastened  by  a  clasp  or  hook  adapted  to 
that  special  purpose  (Figs.  27,  28  and  28^;).  The  bandage 
is  then  removed  by  unwinding  it  from  above  downward; 
the  clamp  devised  by  Langenbeck  (Fig.  29)  can  be  applied 
to  the  upper  turns  of  the  bandage,  which  is  then  removed 
from  below  upward,  or  to  an  independent  cord  or  strap  as 
in  the  preceding  instances.  After  the  removal  of  the  band- 
ages the  limb  will  have  a  cadaverous  aspect,  being  entirely 
devoid  of  blood;  and  the  necessary  operation  can  be  per- 


44 


OPERATIVE   SURGERY. 


formed  and  the  wound  dressed  even  without  the  least  hem- 
orrhage. This,  like  many  other  useful  agents,  has  objec- 
tionable features.  Its  removal  is  often  followed  by  a  large 
amount  of  persistent  oozing;  its  application  may  force  into 
the  circulation  deleterious  elements  which  will  form   the 


Fig.  26. 


Fig.  27. 


basis  of  disease;  it  has  temporarily  paralyzed  the  part  to 
which  it  was  applied,  and  caused  transient  disturbances  of 
the  general  circulation.  These  latter  are  not,  however,  suf- 
ficiently important  to  contra-indicate  its  use.  The  ten- 
dency to  severe  oozing  is  an  objection  which  must  stand 
against  it;  but  its  power  to  force  improper  products  from 


BANDAGES. 


45 


Fig.  28. 


Fig.  28a. 


CASWELCHAZARD.  aCO.WJ.F0aQ. 
Fig.  29. 


diseased  or  injured  parts  into  the  general  circulation  can 
be  obviated  by  omitting  its  application  to  those  parts;  that 


46 


OPERATIVE   SURGERY. 


is,  by  raising  the  limb  and  holding  it  till  well  depleted  by 
the  force  of  gravity,  then  applying  it  to  the  sound  parts, 
above  the  seat  of  injury  or  disease,  and  using  the  rubber 
band  as  before.  The  elastic  bandages  can  be  made  to  serve 
another,  and  very  important  purpose;  that  of  forcing  into 
the  circulation  of  the  trunk  the  blood  in  the  extremities 
in  cases  of  extreme  prostration  from  hemorrhage.  Martin's 
bandage  (Fig.  30)  is  simply  a  rubber  roller,  and  is  used  to 


Fig.  30. 

meet  the  same  indications  as  the  former.  It  can  be,  how- 
ever, more  readily  cleaned  than  a  webbed  one,  and  in  this 
particular  is  preferable  to  it.  Solid  rubber  rings  of 
suitable  size  to  pass  firmly  over  an  extremity  have  been 
used  as  a  substitute  for  the  rubber  bandage.     In  connection 


Pig.  31. 


Fig.  32. 


with  the  digits,  and  even  the  foot,  hand  and  wrist,  they  act 
quite  well,  but  have  not  as  yet  gained  the  support  of  the 
profession. 

Compresses. — Two  kinds  of  compresses  are  in  common 
use;  the  simple  and  the  graduated.  The  former  consists 
only  of  two  or  three  thicknesses  of  cloth,  or  other  suitable 
substance,  folded  into  small  dimensions  and  placed  over 
the  vessel,  or  upon  the  part  which  it  is  desired  to  compress, 


COMPRESSES. 


47 


and  held  in  position  by  a  tightly  drawn  bandage  or  strip  of 
adhesive  plaster. 

The  graduated  compress  may  be  of  the  form  of  an  inverted 


Fig.  33. 


Fig.  34. 


Fig.  34a. 


pyramid  or  cone,  and  oblong  (Figs.  31,  32,  and  33).  Its 
apex  should  be  firm  and  unyielding,  to  give  an  equal  and 
constant  pressure.  The  whole  structure  can  be  made  of 
superimposed  layers  of  cloth,  antiseptic  gauze,  or  adhesive 


48 


OPERATIVE   SURGERY. 


plaster,  of  a  size  and  shape  to  symmetrically  form  its  struc- 
ture. It  is  employed  to  press  upon  the  deep-seated  vessels 
of  the  soft  parts,  and  to  arrest  hemorrhage  from  within  a 
deep  wound  or  cavity.  Care  must  be  employed  in  properly 
adjusting  it,  else  it  may  impede  venous  return,  or  cause 
pain  by  pressing  upon  large  nervous  trunks. 

Digital  pressure  is  the  most  available  of  all  the  pressure 
haemostatics.  It  is  constantly  at  hand,  and  often  intuitively 
seeks  to  arrest  the  flow  of  blood.  It  is  necessary  only  to 
add  to  a  sensitive  finger  and  a  sensible  brain  a  knowledge 


Fig.  35. 


of  where  and  how  to  apply  the  force,  to  rencfer  this  form 
of  pressure  of  inestimable  value.  The  vessel  should  be 
pressed  against  some  resisting  part;  as,  where  it  lies  in 
contact  with  bone.  If  the  bone  be  deeply  seated,  the  vessel 
must  always  be  pressed  towards  it;  unless,  as  is  done  in 
many  cases,  the  limb  be  grasped  so  as  to  bring  the  ends  of 
the  fingers  against  the  vessel  (Figs.  34  and  34^).  If  blood 
flows  from  an  open  wound,  direct  pressure  must  be  made 
upon  the  bleeding  points  with  one  hand,  while  the  other 
hastens   to   compress    the   main    artery   above   the    point 


TOURNIQUETS. 


49 


of  hemorrhage.  It  is  not  necessary  to  use  great  force  to 
interrupt  the  blood  current;  moreover,  to  do  so  tires  the 
arm  and  hand,  and  causes  the  patient  much  pain;  use  just 
force  enough  to  interrupt  all  blood  flow.  The  thumb  of 
the  right  hand  is  the  best  digit  to  apply  at  first;  after- 
wards it  may  be  relieved  in  various  ways  by  the  aid  of  the 
fingers  and  thumbs  of  those  in  attendance.  If  secondary 
hemorrhage  be  anticipated,  or  have  occurred,  the  proper 
point  for  pressure  must  be  indicated   by  some  indelible 


Fig.  36 


Fig.  36a. 


substance  so  that  in  case  of  a  sudden  flow  any  attendant 
can  arrest  it;  with  this  object  in  view,  all  of  the  attendants 
must  be  instructed  in  the  details  of  making  it,  and  be  thor- 
oughly impressed  with  the  necessity  of  instant  action. 

Vessels  that  are  inaccessible  to  digital  compression  can 
be  controlled  often  by  the  handle  of  a  key  or  a  short 
crutch;  the  applied  extremity  of  either  should  always  be 
covered  by  some  soft  material  to  prevent  injuring  the 
vessel. 

Instrumental  Pressure. — Under  this  heading  is  included  the 


50 


OPERATIVE   SURGERY. 


various  forms  of  tourniquets  and  such  other  devices  as  are 
not  directly  connected  with  the  adjustment  of  ligatures  to 
bleeding  vessels.  The  one  in  common  use  was  devised  by 
Petit,  and  is  no  doubt  familiar  to  all  (Figs.  35,  36,  and  36^:). 
It  should  be  cautiously  applied,  and  so  directed  that  the 
pressure  will  compress  the  vessel  against  the  bone,  when 
possible.  A  simple  and  effective  tourniquet  can  be  extem- 
porized by  placing  a  roller  bandage  over  the  site  of  the 
vessel,  confining  it  in  position  by  a  handkerchief  passed 
around  the  arm.  If  the  handkerchief  be  then  tied,  and 
twisted  by  a  stick  the  circulation  will  be  effectually 
stopped  (Fig.  37). 


Fig.  37. 


Davy's  Lever  is  an  implement  devised  by  the  surgeon 
whose  name  it  bears.  It  is  employed  for  the  especial  pur- 
pose of  controlling  hemorrhage  in  amputations  at  the  hip- 
joint.  It  is  passed  up  the  rectum  in  the  direction  of  that 
canal  a  sufficient  distance  to  make  pressure  on  the  com- 
mon iliac  artery,  on  the  side  from  which  the  limb  is  to  be 
removed.  The  upper  extremity  is  then  carried  to  the  right 
sufficiently  to  lie  between  the  bodies  of  the  lumbar  verta- 
brae  and  the  posas  magnus  muscle.  The  lower  extremity 
must  then  be  raised  sufficiently  to  bring  the  requisite  press- 
ure upon  the  vessel  (Fig.  38). 

It  has  been  employed  by  its  designer  and  other  surgeons 
with  signal  success.     It  can  be  more  safely  applied  to  the 


Davy's  lever. 


51 


left  than  the  right  side  on  account  of  the  left  iliac  artery- 
being  nearer  to  the  rectum  than  the  right.  Its  introduc- 
tion must  be  preceded  by  an  injection  of  sweet-oil,  after 


Fig.  38. 


which  it  must  be  cautiously  introduced,  and  held  in  posi- 
tion by  a  gentle,  though  firm  pressure.  If  unnecessary- 
force  be  used  it  may  tear  or  perforate  the  gut.     The  in- 


52 


OPERATIVE   SURGERY. 


/i 


/ 


strument  in  question  is  round,  turned  from  ebony,  and 
from  eighteen  to  twenty  inches  in  length.  The  surface  is 
smooth,  and  its  extremities  rounded; 
its  largest  diameter  is  about  five  eighths 
of  an  inch.  It  can  be  graduated  so  that 
the  surgeon  will  be  able  to  estimate  the 
exact  extent  of  its  entrance  to  the  bowel. 
Its  shape  has  been  variously  modified 
to  meet  the  requirements  suggested  by 
its  more  extended  use. 

Trendelenbtirg  s  Rod. — This  is  likewise 
used  for  the  same  purpose,  but  in  an 
entirely  different  manner  (Fig.  39).  It 
is  passed  through  the  soft  parts  at  such 
a  depth  as  to  include  the  whole  thick- 
ness of  the  proposed  flap.  A  stiff  rubber 
cord  is  then  passed  over  its  extremities 
with  sufficient  force  to  compress  the 
vessel  in  the  tissues  above  it.  The 
flap  can  then  be  made  and  the  vessels 
ligatured  without  loss  of  blood,  after 
which  the  rod  is  withdrawn  and  the  re- 
maining portion  of  the  operation  com- 
pleted in  a  similar  manner.  The 
principle  is  a  feasible  one,  but  it  has  not 
yet  been  enough  practiced  to  become  an 
established  method. 

Acupresszire. — This  plan,  as  a  means 
of  controlling  hemorrhage,  was  devised 
by  Sir  James  Y.  Simpson,  and  is  used 
much  less  in  this  than  foreign  coun- 
tries. It  is  variously  modified  to  meet 
the  common  indication;  the  modifica- 
tions may,  however,  be  reduced  practi- 
cally to  two  in  number:  one,  where 
the  pin  is  carried  through  the  soft  parts 
under  the  vessel,  and  the  point  elevated 
and  pushed  through  at  an  angle  suffi- 
cient to  cause  it  to  close  the  tube  of  the 
canal  (Fig.  42). 

If  this  be  not  effective,  additional 
pressure  can  be  made  by  passing 
beneath  each  extremity  of  the  pin  several  turns  of  cotton 
yarn    or    ordinary   silk    ligature.      This    method  is   often 


Fig.  39. 


ACUPRESSURE. 


53 


employed  to  arrest  hemorrhage  from  small  branches  in 
the  palm  of  the  hand  and  similar  situations,  and  should 
be  supplemented  by  Buck's  pin  conductor  (Fig.  43),  which 
is  passed  beneath  the  vessel  and  out  through  the  integu- 
ment, when  the  pin  is  inserted  into  its  open  extremity  and 


Fig.  40. 


Fig.  41. 


Fig.  42; 


carried  through  by  withdrawing  the  needle.  The  second 
method  is  the  reverse  of  the  first  (Figs.  40  and  41),  the  pin 
resting  upon  and  pressing  the  vessel  downward  upon  the 
deep-seated  tissue,  instead  of  upward  against  the  superficial. 
The  distance  from  the  end  of  the  vessel  at  which  the  press- 


FlG.  43. 

ure  is  applied  depends  upon  its  size;  if  large,  within  one 
half  inch;  if  smaller,  the  distance  can  be  lessened  propor- 
tionately to  its  size. 

Circumclusion,  torsoclusion,  and  retroclusion  are  varia- 
tions of  the  method  of  pin-pressure  produced  either  by 


54  OPERATIVE   SURGERY. 

twisting  or  compressing  the  calibre  of  the  vessel.  These 
various  methods  seem  to  possess  but  one  distinct  practical 
advantage  over  the  occlusion  of  the  same  channels  by  cat- 
gut ligature;  they  can  be  more  safely  applied  to  vessels 
with  brittle  coats  due  to  atheromatous  and  other  changes. 
The  minute  descriptions  of  the  various  modifications  of 
acupressure  can  be  found  in  the  various  text-books  of  the 
day.  The  pins  are  made  of  gold,  silver,  steel  and  iron;  are 
of  various  lengths;  having  glass  heads  and  variously  shaped 
points.     A  further  description  or  an  illustration  is  not  nec- 


FlG.   44. 

essary,  since  they  can  be  satisfactorily  ordered.  Shawl- 
pins,  ordinar}'  pins  and  needles,  can  be  substi':uted,  if  the 
exigencies  of  the  case  require  it. 

Torsion. — This  is  not  as  modern  a  procedure  as  its  limited 
employment  would  warrant  the  belief.  It  consists  in  thor- 
oughly isolating  and  drawing  down  the  vessel,  seizing  it 
firmly  by  a  pair  of  forceps,  about  one  half  inch  above  its 
extremity,  and  twisting  the  end  several  times  till  its  re- 
sistance is  overcome  (Fig.  44);  care  being  taken  to  not 
twist  it  off.  The  blood  is  then  allowed  to  impinge  upon 
the  twisted  portion  before  the  vessel  is  released,  to  test  the 


TORSION. 


55 


completeness  of  the  occlusion.  The  twisting  produces  a 
mutilation  and  breaking  up  of  the  coats  of  the  vessel, 
which  occludes  its  calibre,  and  causes  a  rapid  formation 
of  the  internal  clot.     It  is  evident,  if  the  coats  be  diseased 


CA5WELLXAZAR0.  &CO.VfSSQBD. 


Fig.  45. 


and  brittle,  that  much  caution  is  necessary  in  twisting 
them,  else  a  good  basis  for  the  occurrence  of  secondary 
hemorrhage  will  be  established.  Torsion-forceps,  which 
combine  in  one  instrument  the  holding  and  twisting  forceps, 


Fig.  46. 

are  far  more  convenient  (Fig.  45).  Torsion  as  a  substitute 
for  the  ligature  is  not  considered  with  much  favor  in  this 
country,  except  in  individual   instances.     It  is  commonly 


Fig.  47. 

employed,    however,   to  check  the  small    bleeding  points 
seen  on  the  surface  of  freshly  cut  wounds. 

Forceps,    Serrefines    and    Tenacula. — Since    these    instru- 
ments are  closely  associated  in    common  usefulness,  they 


56 


OPERATIVE  SURGERY. 


can  be  best  spoken  of  in  connection  with  each  other.  The 
spring-catch  fenestrated  forceps  are  the  better.  There  are 
two  patterns  of  these,  the  common  (Fig.  46),  and  those  de- 
vised by  Prof.  Hamilton  (Fig.  47). 

The  expansion  of  the   fenestrated  extremity  carries  the 
ligature  around  the  vessel,  and  it  is  practically  impossible 


Fig.  48. 

to  tie  the  end  of  the  instrument,  as  in  the  case  of  the  sim- 
ple Liston  forceps  (Fig.  48). 

Listen's  forceps,  while  they  are  not  suitable  for  the  com- 
mon purpose  of  catching  bleeding  points,  are  nevertheless 
of  great  service  by  securing  bleeding  points  on  fiat  sur- 
faces. 

The  serresfine  are  of  great  utility  to 
control  bleeding  points  during  an 
operation.  They  can  be  easily  and 
quickly  adjusted,  and  by  their  pressure 
on  the  coats  of  the  small  vessels,  the 
necessity  of  using  a  ligature  thereafter 
may  be  obviated.  They  can  be  used  to 
catch  and  control  bleeding  points  to 
which  the  application  of  a  ligature  is 
impossible,  and  even  be  allowed  to  re- 
main upon  the  vessel  till  all  danger  of 
bleeding  has  subsided.  There  are  seve- 
ral varieties  of  these  instruments.  The 
forcep-serrefine,  which  is  the  largest 
(Fig.  49);  the  angular  and  straight, 
and  those  of  Langenbeck.  The  first 
are  admirably  adapted  to  controlling 
large  vessels,  and  by  their  grasping 
and  self-retaining  forces  can  be  em- 
ployed in  connection  with  other  tis- 
sues. Dr.  J.  L.  Little,  of  this  city,  has 
devised  a  forcep-serrefine  having  a 
fenestrated  biting  extremity,  resembling  in  all  practical 
respects  the  extremity  of  the  fenestrated  artery  forceps. 
The  one  devised  by  Gross  (Fig.  52)  can  be  attached  to  the 
bleeding  point,  handle  unscrewed,  and  the  blades  per- 
mitted to  remain  until  all  danger  of  bleeding  has  ceased. 


Fig. 


TORSION. 


57 


The  smaller  ones  (Figs.  50  and  51)  are  employed  to  catch 
small  bleeding  points. 


Fig.  52. 

Milne's  compressing  forceps 
(Fig-  53)  are  closely  allied  in 
principle  to  the  serrefine;  they 
are,  however,  used  to  compress 
the  smaller  arteries  in  their 
course  through  the  soft  tissues, 
as  the  coronary  arteries  in  the 
operation  for  hare-lip. 

Tenaculum  (Fig.  54). — This 
is  used    to  pick    up    and    draw 


GASWCL.L  JUUiUn)  &C]&.WXFORir« 

Fig.  S3. 


vessels  from  the  soft  parts.  If  a  vessel  be  too  short  to 
be  ligatured  by  the  aid  of  forceps,  it  can  be  transfixed 
along  with  a  small  portion  of  the  contiguous  soft  parts 
by  the  tenaculum,  and  a  ligature  thrown  around  the  com- 
bined tissues  (Fig.  56a.)  If  a  niche  be  made  in  the  tissues 
raised  by  the  tenaculum  at  either  side,  the  ligature  can  be 
more  securely  applied  and  the  vessel  more  firmly  grasped. 
Prince's  tenaculum  forceps  combine  the  principles  of 
both  instruments,  and  can  be  used  with  advantage  (Fig. 

55)- 

The  arterial  compressor  of  Spier,  of  Brooklyn  (Fig.  56), 
is  an  instrument  of  undoubted  efficacy,  but  the  advantages 


58 


OPERATIVE   SURGERY. 


which  it  is  said  to  possess  over  the  ordinary  ligatures  are 
not  of  enough  importance  to  commend  it  to  general  use. 
A  small  portion  of  the  vessel  is  isolated  and 
its  hook-like  extremity  passed  around  it, 
the  handle  is  then  turned  until  the  coats 
are  compressed  sufficiently  to  divide  the 
innermost,  as  in  the  tightening  of  the  or- 
dinary ligature. 

Cautery. — This  remedy,  once  a  universal 
means  of  controlling  hemorrhage,  has  now 
but  a  limited  application.  There  are  three 
varieties  of  cautery  in  common  use:  the 
actual,  the  thermo,  and  galvano  cauteries. 
The  first  requires  the  cautery  irons  (Fig.  57), 
which  should  be  accompanied  by  the  blow- 
pipe (Fig.  58),  although  they  can  be  heated 
by  ordinary  means.  The  blow-pipe  is  far 
better,  since,  during  the  summer  months, 


? 


3 


Fig  .56. 


Fig.  56a. 


Fig.  57. 


or  in  unfavorable  situations,  when  great  haste  is  necessary, 
the  domestic  means  of  heating  them  will  be  inadequate. 


THERMO-CAUTERY. 


59 


The  irons  can  be  made  incandescent,  or  of  a  dull  red  color; 
the  latter  is  the  better,  since  it  burns  more  deeply  and  is 
less  liable  to  be  followed  by  secondary  hemorrhage. 

Therm o-cautery. — The  instrument  designed  by  M.  Paque- 
lin  for  this  purpose  is  exceedingly  ingenious.  It  consists 
of  a   thoroughly  isolated   hollow   handle,    provided   with 


Fig.  55. 

three  movable  platinum  cauteries,  into  which,  after  they 
have  been  heated  in  the  flame  of  a  spirit  lamp,  a  stream  of 
benzine  vapor  is  introduced  by  the  means  of  a  spray  bulb 
connected  by  a  tube  with  the  bottle  containing  it  (Fig.  59); 
this  brings  the  cauteries  quickly  to  the  required  tempera- 
ture, which  can  be  maintained  for  an   indefinite   length  of 


Fig.  58. 


time  by  squeezing  the  rubber  bulb.  The  range  of  the  use- 
fulness of  this  instrument  is  more  extended  than  the  for- 
It  is  used   not  only  for  the  same   purposes,  but  can 


mer. 


be  employed  as  a  cutting  implement  for  the  removal  of 
morbid  growths,  etc.,  when  union  by  first  intention  becomes 
a  lesser  consideration  than  the  annoyance  from  primary 
hemorrhage. 


'6o 


OPERATIVE  SURGERY. 


Galvano-cauiery. — This  method  is  chiefly  employed  in 
connection  with  uterine  surgery,  although  it  is  a  proper  ex- 
pedient in  connection  with  all  operations  where  the  use  of 
the  ecraseur  is  admissible. 

Ligatures. — The  ligature  is  by  far  the  best  general 
agent  for  controlling  hemorrhage.  It  can  be  readily  ap- 
plied, is  easily  portable,  and  can  always  be  obtained  in 
some  form.  Ligatures  may  be  classified  according  to  their 
nature  into  organic  and  inorganic.  The  latter  are  very 
nfrequently  used,  and  then  in  the    form  of  fine  silver  or 


Fig.  s9. 


iron  wire,  which  is  looped  rather  than  tied  around  the 
vessel.  The  organic  comprise  the  hemp,  silk,  and  catgut 
varieties,  which  should  be  made  at  least  from  twelve  to  six- 
teen inches  in  length,  depending  somewhat  on  the  depth  of 
the  wound  into  which  they  are  to  be  applied.  They  must 
be  of  sufficient  strength  to  withstand  the  traction  neces- 
sary to  cause  complete  occlusion  of  the  vessel;  also,  their 
size  must  depend  somewhat  upon  the  force  to  be  employed 
in  tying.  The  requisite  force  to  properly  occlude  a  ves- 
sel cannot  be  estimated  by  ounces  or  pounds,  but  is  large- 


LIGATURES. 


6i 


ly  a  matter  of  experience.  The  traction  should  be  made 
steadily,  and  over  the  ends  of  the  forefingers  or  thumbs 
without  disturbing  the  relations  of  the  vessels  to  its  sur- 
rounding parts  (Fig.  60).     The  giving  away  of  the  inner 


Fig.  60. 


coat  of  a  vessel  indicates  that  the  ligature  is  drawn  suffi- 
ciently tight.  This  cannot  be  felt,  however,  except  in  con- 
nection with  the  large  vessels.  Great  caution  is  to  be  ex- 
ercised to  prevent  any  tissues  other  than  the  walls  of  the 
vessel  being  included  in  the  grasp  of  the  ligature.  If  a 
nerve  be  seized  the  patient  will  be  tormented  by  constant 
pain,  which  may  not  cease  even  with  the  disappearance  of 
the  constricting  agent.  All  tissues  other  than  the  coats  of 
the  vessel  not  only  cause  additional  irritation,  but  delay  the 
separation  of  the  ligature. 

The  Knots. — The  variety  of  the  knot  tied  exercises  an  im- 
portant influence  in  the  security  of  a  ligature.  The  sur- 
geon's knot  is  tied  by  making  two  turns  of  the  ligature  at 
first,  instead  of  one  (Fig.  61);  it  will  not  slip  when  drawn 


Fig.  61, 


tightly,  and  should  always  be  employed  when  the  knot  is 
beyond  the  sight  of  the  surgeon,  otherwise  the  first  half 
of  it  may  slip  without  his  knowledge,  thereby  resulting  in 


62 


OPERATIVE   SURGERY. 


an  imperfect  ligaturing  of  the  vessel.  It  sometimes  hap- 
pens, owing  to  the  ligature  becoming  soaked,  that  it  can- 
not be  drawn  as   tightly  as  one  with  a  single  turn.     If  it 


Fig.  62. 


binds  in  this  manner,  the  tying  of  the  second  part  will  leave 
the  whole  very  insecure. 


Fig.  63. 

_The  Reef  or  Square  Knot. — Either  this  or  the  preceding 
must  always  be  employed  in  tying  a  vessel.     The  reef-knot 


Fig.  64. 


(Fig.  62)  is  easily  confounded  with  the  "  granny  knot"  (Fig. 
63),  which  is  insecure.     The  following  description  of  the 


LIGATURES. 


63 


method   of  tying  the   reef-knot,  taken  from  Heath,  is  too 
graphic  to  be  substituted  by  another.  "  The  ligature  is  to  be 


Fig.  63 


held  in  the  palm  of  the  right  hand  between  the  thumb  and 
finger;  the  end  is  then  to  be  thrown  around  the  forceps 


Fig.  66. 


closely  and  caught  with   the  left  hand,  and   carried  across 
the  right  thumb  and  inserted  between  the  third  and  fourth 


64  OPERATIVE  SURGERY. 

fingers  of  the  right  hand  (Fig.  64).  The  left  at  the  same 
moment  seizes  the  other  end,  and  the  ends  of  the  threads 
are  drawn  out  as  is  being  done  in  Fig.  65.  There  will  now 
be  no  difficulty  in  drawing  the  knot  thus  formed  tight  with 
the  forefingers,  or,  if  preferred,  with  the  thumbs  (Fig.  66). 
To  complete  the  knot  by  making  another  tie,  the  same 
manoeuvre  is  to  be  affected,  taking  care  always  to  begin 
with  the  opposite  hand  to  that  which  began  before.  It 
is  quite  immaterial  which  hand  begins  the  first  part  of  the 
knot,  so  long  as  the  opposite  one  always  begins  the  second 
part;  in  this  way  with  a  little  practice  the  reef-knot  may  be 
unerringly  tied  with  the  greatest  rapidity."  When  the  knot 
is  completed,  it  will  be  seen  that  the  ends  of  the  ligatures 
lie  parallel  with  and  in  contact  with  the  portion  of  the  liga- 
ture which  surrounds  the  vessel.     (See  Fig.  62.) 

The  silk  and  hemp  ligatures  should  be  well  purified  be- 
fore their  application  by  a  strong  solution  of  carbolic  acid, 
or  other  suitable  disinfectant.  If  both  ends  are  to  be  cut 
short  and  the  ligature  allow^ed  to  remain  in  the  wound, 
they  should  have  been  soaked  for  some  time — eight  or  ten 
days  at  least — in  a  solution  of  bichloride  of  mercury 
(igVtf)-  ^^  they  be  thus  treated  in  a  strong  solution  of 
carbolic  acid  their  strength  may  be  impaired.  If  uncar- 
bolized,  they  should  be  freshly  waxed.  After  tying,  one  end 
may  be  cut  short  and  the  other  allowed  to  hang  from  the 
wound. 

Carbolized  catgut  ligatures  are  now  an  established  fact 
in  surgery;  they,  like  other  ligatures,  vary  in  size  and 
strength,  and  a  selection  must  be  made  in  accordance  with 
the  purpose  in  view.  If  a  proper  choice  be  made  they  can 
be  relied  upon  to  fulfil  the  ordinary  indications  of  the  silk 
ligature.  The  requisite  sizes  can  be  obtained  of  the  surgical 
instrument-makers  of  this  city.  Catgut  can  be  tied  by  the 
surgeon's,  or  the  reef-knot;  but  is  less  secure  than  silk.  A 
third  tie  should  always  be  added  to  whichever  of  the  two  is 
employed.  The  ends  are  cut  close  to  the  point  of  tying, 
and  the  wound  closed  irrespective  of  the  presence  of  the 
ligature. 

Chrotnacized  catgut  is  thought  by  some  to  be  superior  in 
many  respects  to  the  carbolized.  It  is  more  flexible,  and 
can  be  carried  and  used  like  the  ordinary  silk  ligature,  re- 
quiring only  to  be  moistened  in  some  aseptic  fluid  before 
it  is  applied. 

Crude  catgut  can  be  purchased  of  those  who  deal  in 


ASSISTANTS   AT   OPERATION.  6$ 

surgical  supplies,  and  aseptacized  to  suit  the  fancy  of  the 
surgeon. 

A  good  plan,  however,  is  that  recommended  by  Lister  in 
his  inaugural  address  of  June  28,  1881. 

"Dissolve  one  part  of  chromic  acid  in  4000  parts  of  dis- 
tilled water,  and  add  to  the  solution  200  parts  of  pure  car- 
bolic acid;  into  this  liquid  immediately  put  catgut  equal  in 
weight  to  the  carbolic  acid.  At  the  end  of  forty-eight  hours 
it  is  sufficiently  prepared.  Then  it  is  to  be  removed  from 
the  solution,  dried,  and  placed  in  one-to-five  carbolized 
oil.     It  is  then  fit  for  use." 

Assistants. — The  number  of  efficient  assistants  necessary 
to  conduct  an  operation  with  ease  is  modified  by  its 
character. 

To  one  must  be  intrusted  the  giving  of  the  anaesthetic, 
and  watching  the  pulse,  respiration,  and  circulation  of 
the  patient.  By  combining  these  duties  the  giver  of  the 
anaesthetic  becomes  the  immediate  observer  of  its  effects, 
and  he  must  always  be  prepared  to  carry  into  execution 
the  various  expedients  that  are  recommended  in  the  com- 
plications attending  anaestliesia.  If  the  temporal  and  radi- 
al pulsations  be  compared  before  its  administration,  the  as- 
sistant will  be  able  to  judge  of  one  from  the  character  of  the 
other.  He  can  then  give  the  anaesthetic,  hold  forward  the 
lower  jaw  to  prevent  swallowing  the  tongue  (see  Fig.  10), 
and  with  the  finger  on  the  temporal  artery,  he  will  be  able 
to  attend  to  the  cares  of  the  case  without  any  interruption. 

To  a  second  should  be  assigned  the  care  of  the  instru- 
ments; giving  them  to  the  surgeon  when  asked  for,  and  re- 
turning them  to  a  place  of  safety  after  being  used. 

To  a  third  may  be  intrusted  the  care  of  the  sponges;  he 
must  always  observe  that  a  suitable  number  be  well 
squeezed  and  placed  at  the  convenience  of  the  operator. 

To  a  fourth  the  ligatures  should  be  given.  He  should 
first  hold  the  limb,  after  which  he  may  either  sponge  or 
ligature  the  vessels,  as  best  suits  the  circumstances  of  the 
case  or  the  fancy  of  the  operator.  The  securing  of  the 
bleeding  points  and  the  necessary  sponging  are  best  done 
by  the  operating  surgeon;  however,'these  are  matters  which 
will  become  self-regulating  as  the  operation  progresses. 
All  assistants  must  be  proficient,  especially  the  one  who 
ligatures  the  vessel  and  administers  the  anaesthetic.  When 
the  surgeon  is  not  able  to  avail  himself  of  a  suitable  num- 
ber of  assistants,  he  must  then  draw  upon  his  own  resour- 
ces.    This  can  by  done  by  placing  the  sponges  and  instru- 


66 


OPERATIVE  SURGERY. 


ments  where  they  can  be  conveniently  reached,  when  he 
can  sponge,  secure,  and  tie  the  vessels.  If  the  circumstan- 
ces demand  it,  he  can  at  the  same  time  control  the  giving  of 
the  anaesthetic.  The  patient  should  be  prepared  for  the  opera- 
tion. The  physical,  legal,  and  spiritual  aspects  of  a  prepa- 
ration have  been  heretofore  considered 
under  various  headings,  consequently 
little  remains  to  be  done  other  than  to 
properly  cleanse  and  shave  the  part  to 
be  operated  upon. 

The  proper  materials  for  uniting  and 
dressing  wou7ids  and  a  knowledge  of  their 
use  must  always  be  had. 

As  soon  as  the  operation  is  completed 
the  wound  should  be  washed  thoroughly 
with  the  strong  solution  of  carbolic  acid 
or  other  antiseptic,  which  not  only  puri- 
fies it,  but  serves  to  check  the  capillary 
oozing  of  the  cut  surfaces.  The  proper 
securing  of  the  cut  surfaces  and  the 
dressing  of  the  wound  involve  three  im- 
portant considerations:  (i)  The  retentive 
coaptation  of  the  divided  tissues;  (2) 
perfect  drainage;  (3)  the  application  of 
some  suitable  protective  dressing.  If 
union  by  first  intention  be  a  desideratum 
the  cut  surfaces  must  be  kept  in  a  per- 
fect coaptation.  For  this  purpose  there 
are  numerous  means  employed.  The 
part  bearing  the  wound  may  be  so  placed 
as  to  avoid  all  muscular  contraction,  or 
undue  tension  of  the  soft  parts.  Strips 
of  adhesive  plaster  with  or  without  roller 
bandages  or  sirriple  compresses  may 
meet  the  indications.  These  agents 
constitute  the  common  dressings  of  a 
less  recent  date,  and  are  at  the  present  time  open  to  the 
strong  objection  of  interfering  with  union  by  first  intention, 
except  they  be  of  an  antiseptic  nature. 

Sutures  may  be  classified  with  reference  to  their  compo- 
sition or  method  of  arrangement.  They  are  of  either  or- 
ganic or  inorganic  nature. 

Those  of  an  organic  nature  are  most  commonly  used; 
but  which  of  these  is  the  better  is  more  a  matter  of  personal 
preference  than  a  surgical  requirement.     The  silk,  hemp. 


Fig.  67. 


SUTURES. 


tl 


catgut  and  horse-hair  sutures  belong  to  this  class,  and  are 
respectively  employed  as  best  suits  the  preference  of  the 
surgeon.  The  silk  and  the  hemp  varieties  are  constantly 
employed,  and  if  they  are  carbolized  they  cause  but  little 
irritation,  and  can  be  removed  without  pain.  The  proper 
introduction  of  sutures  under  all  conditions  requires 
needles  of  various  shapes  and  sizes.     The  curved,  straight ; 


those  with  round  and  edged  extremities.  These  are  too 
familiar  with  all  to  require  other  than  a  passing  mention. 
The  curved  are  used  in  cavities  and  depressions  ;  the 
straight  on  plain  surfaces.  Those  with  an  edged  extremity 
cut  the  tissues  they  pass  through,  while  the  smoother 
separate  the  tissues  and  avoid  the  hemorrhage  that  so  often 
follows  the  track  of  the  former.  The  latter  are,  however, 
inserted  with  greater  difhculty.  Needle  forceps^  or  holders 
(Figs.  67,  68,  and   69),  should    always  be  at   hand  to  aid 


CASWEIL  HAVi^RD  SCO  .W.F.FORD- 
Fig.  69. 


in  conducting  the  needles  steadily  through  the  tissues. 
The  instrument  bearing  the  artery  forceps  at  one  end 
and  the  holder  at  the  other  (Fig.  70)  is  an  admirable  and 
compact  implement. 

Horse-hair. — When  carbolized  these  cause  but  slight  irri- 
tation, and  are  admirably  adapted  to  those  cases  requiring 
but  little  force  to  maintain  coaptation  and  where  scarring 
from  sutures  is  to  be  avoided. 

Catgut  as  a  suture  possesses  the  same  special  advantages 
that  belong  to  it  as  a  ligature.  It  rarely  produces  irritation, 
and  if  allowed  to  remain  will  become  absorbed  without 
ulceration.  If,  however,  much  force  is  required  to  unite 
the  wound,  the  catgut  is  less  reliable  than  the  silk  ligature. 

Inorganic  or  MetaUic  Sutures. — Those  in  common  use  are 


68 


OPERATIVE   SURGERY. 


the  silver  and    iron  wire.      They  can  be  retained   in  situ 
longer  than  the  uncarbolized  silk  or  hemp,  with  less  danger 


Fig.  70. 

from  ulceration.  Their  application  and  removal,  however, 
are  attended  with  more  pain  than  either  of  the  others. 
The  silver  wire  is  more  expensive  than  the  iron;  aside 
from  this  it  matters  little  which  be  used.  The  depth  to 
which  all  sutures  should  be  passed,  the  distance  between 
them  and  their  tension,  depend  upon  the  depth  of  the 
wound  and  the  tendency  of  its  lips  to  separate.  The  object 
of  all  sutures   is  to  hold  the  surfaces  of  wounds  in  close 

contact  until  union  occurs. 
To  accomplish  this  they  must 
be  carried  to  that  depth  and 
be  placed  at  such  distances 
from  each  other  as  will  best 
••*         >'fc*-««l  accomplish       the       purpose. 

"T^  H^  '"^""      They   can    be   supplemented 

•»*»i»rj        f«#9M        |i«'*^^      by  strips  of  adhesive  plaster 

passed  between  them  (Fig. 
71).  They  must  not  be  drawn 
too  tightly,  or  the  tissues 
within  their  grasp  will  be 
strangulated,  causing  ulcera- 
tion and  disfigurement. 
If  the  integument  within  the  grasp  of  the  suture  remain 
white  after  it  is  tightened,  the  suture  must  be  loosened 
before  the  final  dressing  is  completed.  The  length  of  time 
they  should  remain  is  to  be  governed  by  the  danger  of  ulcer- 
ation and  disfigurement,  also  the  tendency  of  the  wound  to 
open.  In  exposed  portions  of  the  body  they  should  be  re- 
moved as  soon  as  notable  irritation  is  observed.  The 
rapidity  and  extent  of  the  ulcerative  process  can  be  lessened 
by  relieving  any  undue  traction  upon  them  by  means  of 
adhesive  plaster  or  other  restricting  influences. 

Different  Forms  of  Sutures. — The  interrupted,  continuous, 
quilted,  hare-lip,  etc.,  are  the  forms  in  common  use.     The 


Fig.  71. 


SUTURES. 


69 


Fig.  72, 


special  varieties  for  intestinal  sewing  will  be  shown  in  con- 
nection  with    operations   upon    the 

intestines. 

The  interrupted  suture   is  the  one 

in   every-day  use,  and    has  a  more 

general  application  than  the    other 

form  (Fig.  72).  It  is  made  by  passing  a  needle  armed 
with  a  well-prepared  suture  through 
the  integument  from  a  line  to  a 
third  of  an  inch  or  more  from  the 
borders  of  the  wound,  depending 
'^^  ^1,  upon  its  size,  depth,  and  retractive 

^^l^"  force.      The   ends  should  then    be 

united  by  a  reef-knot  drawn  with 
sufficient  force  to  oppose  the  sur- 
faces without  puckering  the  skin 
(Fig.  73.)  The  ends  of  the  suture 
can  be  united  in  alternate  sides  of 
the  wound  or  at  one  of  its  points 
of  exit  alone.  The  latter  is  the  bet- 
ter, since,  if   the  dressings  cling  to 

the  extremities,  their    removal   is   less   liable   to  interfere 

with  the  line  of  coaptation. 

The  conti7iuous  suture,  sometimes  called 

the  glover's  (Fig.  74),  is   used  to  unite   i 

superficial  wounds  and  such   others  as 

require  little   force  to   secure  a   proper 

adjustment    of    the    divided    surfaces. 

This  is    made   by   passing   the    needle 

diagonally  from  one  side  of  the  wound 

over  to  the  other. 

The  Quilled  Suture. — This  is  made  by  pass- 
ing several  strong  double  threads    through 


Fig.  73. 


Fig.  74. 


Fig.  75. 


70 


OPERATIVE   SURGERY. 


the  lips  of  the  wound  a  half  an  inch  or  so  apart,  and  tying 
^     I  them  over  quills,  wood,  etc.,  while  they  lie 

^  ^  parallel  with  the  cut  (Fig.  75).  This  is 
used  about  the  vagina,  perineum,  etc.,  when 
deep  gaps  are  to  be  closed. 

The  Twisted  or  Hair-lip  Suture  (Fig.  76). — 

This  is  made  by  pushing  a  pin  through  the 

edges  of   the   wound  and    passing   cotton 

yarn    around    it   to   confine  it  in  position 

(Fig.    77).     The   yarn  should  be  changed 

as  often    as   it  becomes   soiled.     If   it  be 

properly  carbolized   before    application,  it 

lessens    its    tendency   to   cause    irritation. 

An  ordinary  pin  or  needle  can    be   used. 

Fig.  76.  although  those  specially  adapted  for   the 

purpose  are  preferable    (Fig.    78).      They    can  be,  if   not 

spear- pointed,  pushed  or  drawn    through  the   tissues  by 


^^ 


Fig.  77. 


DRAINAGE.  ^I 

aid  of  Post's  or  Buck's  needle  carrier  (Fig.  79).  After 
which  the  points  should  be  nipped  off  and  separated  from 
the  skin  by  a  small  strip  of  adhesive  plaster.  Pins  with 
adjustable   spear-shaped  points  can  be  employed  and  be 


C,  H.  2<  C9 


Fig.  78. 


Fig.  79. 

carried  into  position  by  the  fingers  of  the  operator  (Fig. 

There  are  various  other  special  forms  of  sutures  which 

will  be  considered  under  their  proper .^^ 

headings.  Fig.  80. 

Drainage  is  not  only  of  greatest  importance  in  securing 
successful  union  of  the  divided  surfaces,  but  also  to  the 
safety  of  the  patient.  Good  drainage  to  a  wound  is  as 
potent  to  its  cleanliness  as  is  the  good  drainage  of  a 
dwelling  to  the  healthfulness  of  its  occupants.  No 
one  local  condition  will  interfere  so  materially  with  the 
process  of  healing  or  expose  the  patient  to  greater  consti- 
tutional danger  than  the  collection  and  decomposition  of 
fluids  in  a  wound.  Drainage  may  be  secured  through  de- 
pendent incisions,  or,  better  still,"by  introduction  into  the 
wound  of  a  drainage  tube.  Horse-hairs  or  threads  intro- 
duced into  the  wound  in  some  cases  answer  quite  well. 
The  long  extremities  of  the  silk  or  linen  ligatures,  if  allowed 
to  extend  from  its  most  dependent  portion,  will  drain  it, 
though  somewhat  imperfectlv. 

'CASWELLHAZARD.  ftCCWJ-JORO. 
Fig.  81. 

£/h's's  Drainage  Spiral  {F\g.  81),  or  that  which  is  still  more 
practical,  the  rubber  drainage  tube  (Fig.  82),  will  fulfil  the  in- 
dications more  perfectly.  'An  ordinary  piece  of  black  or 
white  rubber  tubing,  of  about  one  fourth  of  an  inch  in  di- 


7i  OPERATIVE  SURGERY. 

ameter,"with  holes  in  the  sides  at  irregular  intervals,  can  be 
inserted  into  the  bottom  of  the  wound  cavity  through  its  most 
dependent  portion.  Another  can  be  introduced  into  the  up- 
per portion  of  the  cavity  through  the  uppermost  angle  of 
the  wound.  The  size  should  vary  with  the  dimensions  of 
the  wound.  They  are  more  often  too  small  than  too 
large.  They  must  be  fastened  in  position,  or  they  may 
slip  into  the  wound;  this  can  be  done  by  passing  a  thread 
through  the  projecting  extremity  and  tying  it  around  the 
limb  or  fastening  it  securely  by  adhesive  plaster.  If  a  sin- 
gle tube  be  passed  so  as  to  protrude  from  both  sides  of  the 
wound,  it  can  be  securely  fastened  by  passing  an  ordinary 
safety  pin  through  each  extremity.  However,  it  is  better 
to  use  two  short  tubes  instead  of  one  long  one  ;  the  latter 
introduces  into  the  wound  a  superfluous  amount  of  rubber, 
which  does  not  perform  a  duty  sufficient  to  compensate  for 


Fig.  82. 

its  presence.  In  either  case  it  is  necessary  to  allowfor  the 
swelling  of  the  parts,  else  the  pins  or  threads  may  cause 
constriction  of  the  injured  parts.  The  outer  extremities 
should  then  be  cut  off  flush  with  the  soft  tissues.  The 
wound  can  be  washed  through  the  upper  tube,  while  all 
discharges  will  pass  from  the  lower  one.  The  length  of 
time  they  should  remain  must  depend  upon  the  character 
and  amount  of  the  discharge.  If  the  amount  be  small  and 
of  inoffensive  nature,  they  can  be  removed.  It  must  not 
be  forgotten  that  they,  as  foreign  bodies,  may  excite  the 
discharge  for  which  they  are  retained  to  carry  off. 

Protective  Dressings. — These  include  the  ordinary  dress- 
ings, such  as  one  who  is  a  long  wa}'  from  the  basis  of  sup- 
plies, or  not  a  believer  in  the  modern  methods,  would 
employ:  as  covering  the  wound  with  a  linen  cloth  kept 
moist  with  a  weak  solution  of  carbolic  acid,  or  water;  the 
application  of  adhesive  plaster,  and  covering  it  with  medi- 
cated cloths  held  in  position  by  bandages  or  plasters.  Of  the 
modern  methods,  the  one  bearing  the  name  of  Lister,  its 
designer,  is  deserving  of  especial  mention,  not  only  on  ac- 
count of  its  acknowledged  worth,  but  also  from  the  fact 


ANTISEPTIC   SYSTEM. 


73 


that  other  methods  involving  similar  principles  are  advo- 
cated, the  result  being  sought  by  the  aid  of  different  agents. 

The  requirements  for  the  Lister  treatment  are  the  atom- 
izer, or  spray,  carbolic  acid  solution,  drainage  tube,  protec- 
tive, antiseptic  gauze,  Mcintosh,  catgut  ligatures;  and  that 
everything  to  be  brought  in  contact  with  the  wound  be 
made  antiseptic  by  a  strong  solution  of  carbolic  acid. 

The  Aiitiseptic  Spray  Apparatus  consists  of  a  kettle,  lamp, 
spray  tube,  and  a  bottle  to  contain  the  solution  of  strong 
carbolic  acid  (Fig.  83).     The  spray  is  produced  and  directed 


Fig.  83. 

upon  the  site  of  the  operation  before  the  first  cut  is  made. 
It  should  be  continued  through  the  whole  operation,  and 
until  the  wound  is  surrounded  by  the  protective  dressing. 
It  is  always  to  be  used  when  the  wound  is  redressed. 
The  arteries  are  tied  with  catgut;  the  wound  is  united  by 
the  same  material  and  washed  with  the  carbolic  solution, 
and  the  drainage  tube  is  inserted  as  before  described. 

The  protective  (which  somewhat  resembles  oiled-silk)  is 
placed  over  the  wound  and  extended  an  inch  or  so  from 
its  border,  with  openings  for  thenmouths  of  the  drainage 
tubes.  A  small  piece  of  the  ant  septic  gauze  wet  in  the 
strong  solution  of  carbolic  acid  can  be  laid  over  and  beyond 
the  protective.  Numerous  layers  of  the  antiseptic  gauze 
are  then  made  to  cover  the  part,  their  borders  extending 
a  good  distance  or  so  beyond  the  edge  of  the  w^ound. 
Around  the  whole  is  wrapped  the  Mcintosh,  which  is  con- 
fined in  position  by  bandages  made  of  tlie  antiseptic  gauze. 


74  OPERATIVE   SURGERY. 

This  dressing  can  be  removed  on  the  second  or  third  day, 
the  wound  washed  out,  protective  and  Mcintosh  purified, 
and  unsoiled  gauze  substituted,  after  which  it  need  not  be 
examined  again — other  things  being  equal — within  a  week 
or  ten  days,  unless  the  discharges  soak  through  the  dressing. 

At  the  present  time,  more  often  than  otherwise,  the  spray 
is  not  employed.  If  the  spray  be  omitted,  the  surface  to 
be  operated  upon  should  be  thoroughly  scrubbed  with  soap 
and  water  and  afterwards  washed  with  a  strong  solution 
of  carbolic  acid  or  some  other  suitable  disinfectant,  and  the 
surfaces  contiguous  to  it  covered  by  towels  saturated  by 
the  same  disinfecting  solution,  which  should  be  kept 
thoroughly  wetted  by  it  during  the  operation.  The  opera- 
tion wound  must  likewise  be  thoroughly  douched  with  some 
disinfecting  fluid  during  the  entire  course  of  the  procedure. 
In  all  other  respects,  however,  the  preceding  details  are 
carried  out. 

Cotton-batting  Dressing. — Cotton  batting,  or  that  which  is 
better,  borated,  or  salicylated  cotton,  is  frequently  em- 
ployed as  a  protective  dressing  in  place  of  the  antiseptic 
gauze.  The  results  obtained  warrant  the  belief  that  it  is 
entitled  to  be  considered  worthy  of  an  extended  applica- 
tion. It  exerts  a  very  desirable  uniform  pressure  upon  the 
parts  to  which  it  is  applied,  thereby  aiding  coaptation  and 
fostering  union. 

Iodofor7n  Dressing. — Iodoform  is  dissolved  in  ether,  and 
after  the  operation  it  is  thrown  upon  the  cut  surface  by 
means  of  an  ordinary  atomizer.  The  ether  evaporates, 
leaving  the  iodoform  evenly  deposited  over  the  cut  surfaces. 

It  can  be  better  applied  if  pulverized  and  blown  into  the 
wound  by  an  insufflator.  The  wound  is  then  closed  by 
antiseptic  sutures,  drainage  tubes  introduced,  and  the  whole 
surrounded  by  antiseptic  gauze,  upon  the  surface  of  which 
iodoform  has  been  freely  sprinkled,  corresponding  to  the 
vacuity  of  the  wound.  This  is  bandaged  in  place  and 
allowed  to  remain  until  the  dressing  becomes  solid,  when 
it  is  redressed  as  before. 

The  odor  of  the  iodoform  and  its  occasional  deleterious 
effects  upon  the  nervous  system  of  the  patient  has  made  its 
use  infrequent  and  cautious. 

Iodoform  gauze  is  made  use  of  in  many  instances. 

Peat  Dressing. — Into  a  small  carbolized  gauze  bag  the 
light  peat  or  turf  is  introduced,  combined  with  2\  per  cent 
of  iodoform;  over  this  a  larger  bag  filled  with  carbolized 


ANTISEPTIC   SYSTEM.  75 

peat  is  applied,  and  the  whole  bandaged  firmly  in  position. 
The  fine  peat  serves  admirably  to  make  equitable  pressure 
and  absorb  the  discharges,  and  need  not  be  re-applied  until 
it  has  become  soiled. 

Bichloride  of  Mercury  Dressing. — By  this  method  the 
dangers  attending  the  use  of  carbolic  acid  and  iodoform 
are  avoided;  at  the  same  uime  a  cheap  and  inoffensive  sub- 
stance is  utilized.  It  is  used  with  the  spray  (3-^07)  or  as 
a  wash  for  the  wound  (-joVo)-  Sponges,  ligatures  and  su- 
tures are  soaked  in  solutions  varying  in  strength  from  10 
to  75  grains  to  the  pint  of  water  or  alcohol,  the  latter  being 
used  for  the  ligatures  and  sutures,  in  which  they  are  kept 
for  three  or  four  hours,  thence  removed  to  a  much  weaker 
one.  Catgut  can  be  treated  in  substantially  the  same  man- 
ner by  allowing  it  to  remain  ten  or  twelve  hours  in  the 
alcoholic  solution,  from  which  it  is  to  be  taken  and  intro- 
duced into  a  weaker  one  (one  half  of  i  per  cent)  containing 
a  drachm  or  so  of  gl5xerine. 

The  protective  dressing  can  be  saturated  with  a  strong 
solution  (50  gr.  to  the  pint)  and  applied  in  the  same  man- 
ner as  before. 

Instruments  can  be  purified  with  it,  although  it  lessens 
their  cutting  power. 

This  dressing  can  be  recommended  as  one  possessing 
efficiency  and  safety.  Alcohol,  thymol,  eucalyptol,  and  the 
essential  oils  have  been  recommended  as  antiseptic  agents, 
but  with  insufficient  assurance  to  warrant  their  employ- 
ment in  place  of  the  other  well-established  agents. 

Open  Dressing. — The  so-called  open  dressing  consists  in 
washing  the  wound  cavity  with  the  strong  carbolic  acid 
solution  at  the  completion  of  the  operation,  after  which  it 
is  placed  upon  a  suitable  cushion  of  oakum,  and  over  it  is 
laid  a  thin  piece  of  gauze,  which  is  kept  moistened  with  a 
solution  of  carbolic  acid.  The  wound  is  washed  two  or 
three  times  daily  by  gentle  irrigation  with  a  carbolic  solu- 
tion, after  which  balsam  of  Peru  is  poured  into  it.  All  the 
dressings  are  to  be  kept  clean. 

The  success  which  attended  this  method  in  the  hands  of 
the  late  Prof.  James  R.  Wood  can  but  cause  the  skeptical 
surgeon  to  wonder  at  the  necessity  of  the  tedious  details 
of  the  Lister  and  other  methods. 

Precautionary  Requirements. — These  requirements,  and 
their  importance  were  stated  some  time  since. 

Stimulants,  of  which  brandy,  whisky,  champagne,  ammo- 


'j6  -  OPERATIVE   SURGERY. 

nia,  and  nitrite  of  amyl,  etc.,  etc.,  are  examples,  enter  into 
common  use.  Some  one  or  more  of  these  should  be  at 
hand  in  all  operations,  irrespective  of  its  length  or  require- 
ments. 

For  purposes  of  administration  the  hypodermic  and 
Davidson's  s)''ringes  are  most  convenient.  Under  no  cir- 
cumstances must  fluids  be  administered  by  the  mouth,  if 
the  patient  be  unconscious,  except  by  the  medium  of  a 
stomach  tube. 

Tenaculum. — Its  use  has  been  sufficiently  emphasized  to 
render  the  importance  of  its  presence  evident. 

Electric  Battery. — This  must  always  be  thought  of  when 
the  nature  of  the  operation  or  condition  of  the  patient  may 
give  rise  to  the  subsequent  failure  of  the  circulatory  or  res- 
piratory powers. 

Tracheotoffiy  Tube. — Although  this  is  not  necessary  to  the 
performance  of  tracheotomy  or  laryngotomy  when  indica- 
tions suddenly  arise  calling  for  either,  yet  it  is  better  it  be 
at  hand.  The  surgeon  must  not  overlook  the  fact  that  the 
death  of  a  patient  due  to  the  absence  of  a  tube  or  to  the 
loss  of  time  consumed  in  seeking  for  one  is  most  unpardon- 
able, and,  to  say  the  least,  entitles  him  to  censure. 

Elastic  Bandages. — These  are  not  only  important  in  pre- 
venting the  loss  of  blood,  but,  as  heretofore  stated,  doubly 
important  when  applied  to  the  limbs  in  forcing  the  blood 
contained  in  them  into  the  centre  of  circulation,  as  in  cases 
of  impending  death  from  shocks  due  to  the  loss  of  blood. 
They  are,  in  my  opinion,  of  greater  practical  utility  for  im- 
mediate use  than  the  more  elaborate  instruments  employed 
in  transfusion.  They  will  certainly  bridge  over  the  inter- 
val of  time  necessary  to  prepare  for  the  use  of  the  transfu- 
sion apparatus  better  than  any  other  expedient. 

Artificial  Respiratio7i. — No  one  can  be  safely  intrusted  to 
administer  an  anaesthetic,  or  to  attempt  any  operative  pro- 
cedure, who  is  not  familiar  with  the  manipulations  neces- 
sary to  the  proper  performance  of  this  act.  It  is,  in  fact, 
the  only  one  of  the  requirements  which  can  and  should  be 
continuously  employed  until  the  safety  of  the  patient  is 
assured,  or  until  death  is  an  established  fact. 

Finally,  a  surgeon  should  never  begin  an  operation,  be 
it  of  greater  or  lesser  magnitude,  without  having  carefully 
rehearsed  its  various  steps  in  his  mind,  together  with  the 
possible  complications  that  may  arise  and  the  best  means 
of  combating  them. 


LIGATURE   OF  ARTERIES.  'J'^ 

Preparations  of  this  kind  serve  to  distinguish  the  careful 
and  conscientious  surgeon  who  places  a  proper  value  upon 
human  life  and  a  just  professional  reputation,  from  the  one 
who  operates  only  because  the  opportunity  is  offered,  and 
considers  the  details  tedious  or  worthless  because  he  has  not 
had  sufficient  patience  or  faith  to  practice  them.  He  trusts 
to  luck,  and  attributes  his  results  to  an  inscrutable  Provi- 
dence ;  more  especially  when  the  patient  succumbs. 


LIGATURE  OF  ARTERIES. 

Arteries  are  ligatured  in  their  continuity  or  at  their  di- 
vided extremities.  Under  this  heading,  however,  will  be 
considered  the  ligaturing  in  their  continuity  only.  Nearly 
all  arteries  to  which  ligatures  are  thus  applied  can,  from 
their  association  with  the  soft  and  hard  parts,  be  said  to 
possess  certain  guides,  which,  when  carefully  adhered  to, 
indicate  with  precision  their  position  beneath  the  surface. 

The  guides  to  ligaturing  arteries  in  the  living  subject  are 
practically  four  in  number,  (i)  The  linear  guide.  (2)  The 
muscular  guide.  (3)  The  contiguous  anatomical  guide. 
(4)  The  pulsation  and  color  of  the  vessel. 

The  linear  guide  to  an  artery  is  a  line  drawn  upon  the  ex- 
ternal surface  so  as  to  correspond  with  the  established 
course  of  the  vessel  beneath.  Its  extremities  are  usually 
indicated  by  the  relations  which  the  vessel  bears  to  fixed 
bony  prominences. 

The  muscular  gtiide  is  based  upon  the  relation  which  the 
vessel  bears  to  some  portion  of  a  well-developed  superficial 
muscle,  the  outline  of  which  can  be  quite  readily  traced  if 
the  muscle  be  placed  upon  the  stretch.  If  the  border  of  a 
muscle  be  given  as  the  guide,  it  must  not  be  forgotten  that 
in  case  it  be  unusually  developed,  or  have  a  broader  origin 
and  insertion  than  common,  it  will  overlap  the  vessel,  and 
thus  may  lead  the  surgeon  astray.  Under  these  circum- 
stances he  must  direct  his  attention  unerringly  to  the  con- 
tiguous anatomical  guides,  which  include  the  relations  that 
a  vessel  bears  to  its  immediate  surrounding  parts;  and  when 
taken  in  connection  with  its  pulsation,  lead  directly  to  it. 
The  contiguous  guides  may  be  muscular,  if  a  muscle  be 
ascertained  to  bear  an  established  relation  to  it;  or  bony, 
when  a  bony  prominence  is   in  close  contact  with  it;  or 


78 


OPERATIVE   SURGERY. 


nervous,  when  a  certain  nerve  is  known  to  lie  in  a  definite 
relation  with  it;  or  vascular,  when  veins  of  an  established 
arrangement  exist.  And  finally,  the  sheath  of  the  vessel 
itself,  when  it  is  present.  Some  of  the  large  vessels,  of 
which  the  common  carotid  and  femoral  arteries  are  the 
most  striking  examples,  possess  well-developed  sheaths. 
The  smaller  arteries  are  surrounded  by  a  greater  or  lesser 
amount  of  areolar  tissue.  The  larger  arteries,  as  the  popli- 
teal, femoral,  and  subclavian,  are  each  accompanied  by  a 
single  vein  which  commonly  runs  in  a  definite  relation  with 
them.  The  smaller  ones,  those  of  the  extremities,  etc.,  are 
attended  by  satellite  veins,  known  as   the  venae  comites, 


Fig.  84. 


usually  two  in  number;  however,  that  is  not  invariable, 
since  three  or  more  are  often  seen.  The  vessels  are  distin- 
guished from  each  other  by  the  darker  color  of  the  veins 
and  the  lighter  or  pinkish  color  of  the  artery.  If  three  ves- 
sels are  seen,  the  middle  one  is  almost  certain  to  be  the 
artery;  if  more  than  three  exist,  the  third  vein  usually  rests 
upon  the  artery;  if  pressure  be  made  upon  them,  the  veins 
are  distended  and  the  artery  is  collapsed  beyond  the  point 
of  pressure.  If  to  these  facts  be  now  added  the  pulsation 
of  the  artery,  its  location  is  assured.  The  operator  who 
relies  exclusively  upon  the  arterial  impulse  as  a  guide,  may 
be  led  astray  by  the  transmitted  pulsations  of  other  vessels, 
or  by  the  functional  movements  of  the  parts  in  which  the 
artery  is  located. 

Having  determined  the  anatomical  details,  the  portion 
of  the  body  in  which  the  vessel  is  contained  is  placed  in 
position  to  afford  all  available  room  and  the  best  possible 


LIGATURE  OF  ARTERIES.  79 

light;  the  portion  of  the  vessel  is  then  selected  at  which  the 
surgeon  feels  best  assured  of  the  absence  of  a  branch  of 
sufficient  size  to  interfere  with  the  formation  of  an  internal 
clot.  The  primary  incision  is  then  made,  the  centre  of 
which  should,  if  possible,  correspond  to  the  point  of  the 
vessel  to  which  the  ligature  is  to  be  applied.  The  length 
of  the  incision  will  depei.d  upon  the  depth  of  the  vessel, 
and  should  always  be  of  sufficient  extent  to  afford  easy  ac- 
cess to  it.  If  the  thumb  and  finger  be  employed  to  make 
tense  and  to  steady  the  integument,  great  care  must  be 
taken  to  make  the  traction  equal  on  the  respective  sides 


Fig.  8s. 

(Fig.  84),  Otherwise,  after  the  tissues  are  released,  the  cut 
will  be  outside  the  line  of  the  vessel,  which,  if  not  noticed, 
will  lead  the  surgeon  astray;  besides,  its  irregularity  will 
interfere  with  the  necessary  space  and  light  as  well  as 
the  subsequent  drainage.  The  external  incision  should  be 
made  with  one  sweep  of  the  knife,  rather  than  by  repeated 
cuts,  which  tend  to  chop  the  tissues,  increasing  the  danger 
of  suppuration,  and  correspondingly  lessening  the  prospects 
of  union  by  first  intention. 

The  fascia  is  pinched  up  by  the  thumb  forceps,  or  tenac- 
ulum, and  carefully  nicked  with  a  scalpel,  after  which  a 
grooved  director  is  cautiously  passed  beneath  it,  upon  which 


8o 


OPERATIVE  SURGERY. 


it  is  then  divided.  The  fascia  should  not  be  incised  the  full 
length  of  the  integumentary  cut.  The  nearer  the  approach 
to  the  vessel,  the  shorter  should  be  the  line  of  the  separa- 
tion of  the  tissues,  so  that  when  the  vessel  is  reached  the 
bottom  of  the  wound  will  somewhat  resemble  an  inverted 
triangle,  with  its  apex  corresponding  to  the  artery. 

The  tissues  beneath  the  fascia  are  to  be  gentl)^  separated 
by  the  fingers,  handle  of  the  scalpel,  or  director;  using  the 
knife  only  when  necessary,  until  the  sheath  of  the  vessel  is 
reached,  when  a  small  opening  is  made  into  it — about  one 
fourth  of  an  inch  being  ample — of  sufficient  size  to  pass  the 
needle  with  ease.  This  opening  is  made  by  picking  up  the 
sheath  or  condensed  tissue  with  the  thumb  forceps,  and 
with  the  scalpel  at,  or  nearly  at  right  angles  with  the  for- 
ceps, carefully  cutting  out  a  button-hole-shaped  piece  of  a 
suitable  size  (Fig.  85). 

The  borders  of  this  opening  are  then  to  be  separately 
raised,  to  inform  the  operator  if  deeper  tissues  still  surround 
the  vessel;  if  so,  they  should  be  incised  in  a  similar  manner. 
When  the  peculiar  pinkish  white  appearance  of  its  coats 
are  seen,  the  side  of  the  cut  in  the  sheath  nearest  to  the 
contiguous  vein  should  be  grasped  and  raised  by  the  for- 
ceps, and  the  aneurism  needle,  or  probe,  armed  with  a  liga- 
ture, carefully  passed  around  the  vessel,  being  carried  from 
the  contiguous  vein  (Fig.  86).  When  its  extremity  ap- 
pears at  the  other  side  the  ligature  is 
seized  by  the  forceps  and  one  end 
drawn  through,  while  the  other  ex- 
tremity is  retained  in  position  by  the 
withdrawal  of  the  needle.  If  the  ves- 
sel be  sufficiently  superficial,  the  liga- 
ture can  be  passed  through  the  eye  of 
the  needle  after  its  passage  beneath 
the    artery    (Fig.    87).      If    now    all 


Fig.  87.  Fig.  86. 

doubts  be  settled  as  to  the  identity  of  the  vessel,  the  liga- 


INSTRUMENTS   USED  IN  LIGATION. 


ture  is  tied  by  making  either  the  surgeon's  or  the  reef-knot. 
If  the  ligature  be  of  catgut,  cut  both  ends  short  and  dress 
the  wound;  if  silk,  cut  one  extremity  short  and  allow  the 
other  to  hang  from  its  most  dependent  position.  This  ex- 
tremity should  be  secured,  so  that  it  will  not  be  unneces- 


ffli 


CflSWEUJHAZAfiiJ,  &CO.yiFJOHa 


Fig.  88. 


sarily  drawn  upon  when  the  wound  is  dressed.  The  length 
of  time  the  ligatures  are  to  remain  depends  upon  the  size 
of  the  vessel,  and  will  be  considered  in  connection  with  the 
ligaturing  of  the  individual  arteries. 

Insimments  required    to   Ligature   Arteries. — An  ordinary 
scalpel,  a  flexible  grooved  director,  thumb-forceps,  tenacu- 


FlG.  89. 

la,  retractors,  and  an  aneurismal  needle  armed  with  a  liga- 
ture. 

Retractors  vary  in  size  and  shape.  The  ones  recommended 
by  Profs.  Mott  (Fig.  88)  and  Parker  (Fig.  89)  are  appro- 
priate for  all  practical  purposes.     If  neither  be  at  hand,  one 

CASWEIXHAZABD.  &CO.VJ.Fi^0RQ. 


Fig.  90. 

can  be  devised  by  bending  the  handle  of  the  common  table- 
spoon to  the  necessary  angle. 

Aneurismal  Needle. — These  vary  in  size,  shape,  and  ar- 
rangement. The  simplest  form  is  combined  with  a  direc- 
tor (Fig.  90);  another  in  common  use  has  a  broader  ex- 


82 


OPERATIVE   SURGERY. 


1C^^^^^ 


Fig.  91. 


Fig.  92. 


Fig.  93. 


LIGATION  OF  ABDOMINAL  AORTA.  83 

tremity  with  a  suitable  handle  (Fig.  91);  still  another  with 
adjustable  points  for  the  purpose  of  securing  deep-seated 
vessels.  The  points  must  be  securely  screwed  into  posi- 
tion, else  the  turning  and  twisting  of  turns  necessary  to 
pass  it  may  loosen  the  points,  causing  it  to  become  a  source 
of  annoyance  instead  of  an  advantage  (Fig.  92).  Also 
one  with  a  lateral  curvature  may  be  employed.  Fig.  93 
is  a  representation  of  the  safest  needle  with  movable  points 
now  in  use.  It  is  known  as  the  "  Movable  Immovable 
Aneurismal  Needle,"  and  also  as  the  "  Student's  Aneurismal 
Needle."  It  was  devised  by  Dr.  S.  W.  Fletcher,  of  Pepper- 
ell,  Mass.,  while  a  student;  hence  the  name  sometimes 
given  to  it. 
Ligature  of  the  Abdominal  Aorta, — This  vessel  can  be  liga- 


FlG.  94. 

tured  at  its  lower  two  inches — that  is,  below  the  origin  of 
the  inferior  mesenteric — by  two  or  three  methods. 

Linear  guide  is  the  linea  alba. 

The  omentum,  intestines,  and  mesentery  lie  in  front;  the 
left  lumbar  veins,  receptaculum  chyli,  thoracic  duct,  and 
vertebral  column  behind,  on  the  right  the  inferior  vena 
cava,  vena  azygos,  and  thoracic  duct.  At  the  left  no  struc- 
tures are  liable  to  be  injured  (Fig.  94). 

Operation. — First  method  {Cooper  s). — An  incision  is  made 
three  or  four  inches  in  length  a  little  to  the  left  of  the  um- 
bilicus, its  centre  corresponding  to  it.  (See  "A,"  Fig.  95.) 
The  peritoneum  is  divided  to  the  same  extent  on  a  grooved 


84 


OPERATIVE  SURGERY. 


director;  the  omentum,  mesentery,  and  intestines  are  then 
pushed  upward,  the  peritoneum  scratched  through  with  the 
finger-nail,  or  a  director;  the  finger  is  passed  beneath  the 
vessel,  and  the  needle  carried  around  it  from  right  to  left, 
the  ligature  tied  and  the  wound  closed. 

Second  Method  [Murray's). — Linear  guide:  From  the  apex 
of  the  tenth  rib  to  within  an  inch  of  the  anterior  superior 
spinous  process  of  the  ilium.     (Fig.  95,  "B"), 

The  left  ureter  lies  to  its  outer  side. 

Operation:  Divide  the  various  tissues  on  a  grooved  direc- 
tor down  to  the  subserous  tissue;  the  hand  is  then  inserted, 


Fig.  95. 


and  the  peritoneum,  intestines,  and  ureter  are  raised  upward 
and  inward,  readily  exposing  the  vessel  to  view.  The 
artery  is  then  raised  with  the  finger  and  the  ligature  passed 
as  before.  It  can  be  reached  through  an  incision  extending 
from  the  end  of  the  last  rib  to  the  anterior  superior  spinous 
process  of  the  ilium. 

Results. — It  has  been  ligatured  ten  times,  and  in  every 
instance  has  proved  fatal;  death  occurring  from  within 
three  or  four  hours  to  ten  days. 

Cofnmofi  Iliac  Arteries. — These  vessels  average  about  two 


Ligation  of  common  iliac.  S5 

inches  in  length,  and  should  be  ligatured  at  a  point  nearest 
to  their  middle.  They  commonly  begin  at  the  left  of  the 
middle  of  the  body  of  the  fourth  lumbar  vertebra,  and  pass 
downward  and  outward  to  the  sacro-iliac  synchondroses. 
A  line  drawn  between  the  highest  portions  of  the  iliac  crests 
corresponds  very  nearly  tc  their  point  of  origin.  Two  lines 
drawn  a  little  to  the  left  of  the  centre  of  this  one,  and  car- 
ried downward  and  outward  between,  but  a  little  nearer 
the  pubes,  than  the  anterior  spinous  process  of  the  ilium, 
mark  the  course  of  the  vessels  downward. 

There  are  two  general  methods  of  access  to  them;  one, by 
entering  the  abdominal  cavity  in  front,  the  other  by  raising 
the  peritoneum  through  an  incision  made  at  the  side  of  the 
abdomen. 

First  method :  At  this  time  this  method  is  not  favorably 
considered  as  a  substitute  for  the  latter,  except  in  cases 


Fig.  96. 

where  the  latter  is  inadmissible.  If  the  surgeon  be  able 
to  command  complete  asepsis,  the  advisability  of  the  latter 
operation  is  greatly  enhanced;  if  otherwise,  it  should  not 
be  attempted  unless  the  situation  of  the  disease  calling  for 
it  renders  the  former  impracticable.  The  outer  side  of  the 
rectus  muscle,  or  more  properly  the  linea  semilunaris,  is  the 
best  superficial  guide  to  the  vessel  in  this  method.  The 
linea  semilunaris  extends  from  the  lower  portion  of  the 
seventh  rib  in  a  slightly  outwardly  arched  direction  down- 
ward to  the  spine  of  the  pubes.  In  a  normal  abdomen 
these  lines  are  about  three  inches  from  the  umbilicus.  An 
incision  through  the  linea  alba  below  and  even  extending  a 
little  above  the  umbilicus,  maybe  employed  likewise.  The 
relations  of  the  common  iliac  arteries  and  veins  are  intricate 
and  dissimilar  (Fig.  96),  and  should  be  carefully  memorized. 


OPERATIVE   SURGERY. 


IMPORTANT  ANATOMICAL  RELATIONS. 

Plan  of  the  Relations  of  the  Common  Iliac  Arteries. 
In  fro7it.  In  front. 

Peritoneum. 
Rectum. 

Superior  hemorrhoidal  artery. 
Ureter. 


Peritoneum. 
Small  intestines. 
Ureter. 


(  Right  ) 
<  Common  V 
(     Iliac,     j 


Outer  side. 
Vena  cava 
Right  common 

iliac  vein. 
Psoas  muscle. 


Inner  side. 

Left  common 

iliac  vein. 


(      Left 
\  Common 
/     Iliac. 


Outer  side. 
Psoas  muscle. 


Behind. 

Right  and  Left  common 

iliac  veins. 


Behind. 

Left  common 

iliac  vein. 


Operation  :  An  incision  five  inches  in  length  and  three 
inches  to  the  left  of  the  median  line  is  made  into  the  ab- 
dominal cavity;  intestines  are  pushed  aside,  and  a  small 


Fig.  97. 


opening  is  scratched  through  the  peritoneum;  and  the  ves- 
sel ligatured  by  passing  the  needle  from  without  inward 
on  the  right  and  within  outward  on  the  left  side.  That  is 
to  say,  pass  it  f^-om  the  veins  nearest  the  vessel.  The 
wound  is  then  closed  as  in  ovariotomy. 


LIGATION  OF  COMMON  ILIAC. 


87 


Results :  They  are  thus  far  sufficiently  satisfactory  to  war- 
rant its  employment  when  other  methods  are  inadmissible. 

Second  method:  Without  opening  into  the  abdominal 
cavity. 

Linear  Guide  to  Operation. — (i.)  (Crampton.)  A  line  drawn 
from  the  apex  of  the  last  rib,  downward  and  a  little  for- 
ward nearly  to  the  crest  of  the  ilium,  then  carried  forward 
parallel  with  it  to  the  anterior  superior  spine  (Fig.  97). 

(2)  Is  a  line  drawn  downward  from  the  tip  of  the 
eleventh  rib  to  one  and  a  half  inches  within  the  anterior 


Fig.  98. 

superior  spine,  then  carried  downward  and  forward  and 
curved  sharply  upward,  sharply  terminating  above  the  in- 
ternal abdominal  ring  (Fig.  98). 

Muscular  Guide. — There  is  no  superficial  muscular  guide 
except  the  rectus  in  the  median  operation.  The  inner  border 
of  the  psoas  magnus  is,  however,  an  undeviating  and  mark- 
edly prominent  deep  muscular  guide.  The  contiguous 
anatomy  in  this  method  is  indicated  by  the  plan  of  the 
preceding. 

Operation. — Place  the  patient  on  the  back,  inclined  to  the 


88  OPERATIVE   SURGERY. 

opposite  side,  with  the  thighs  flexed  sufficiently  to  relax 
the  abdominal  walls.  By  repeated  divisions  on  the  grooved 
director,  the  various  layers  of  the  tissues  composing  the 
abdominal  walls  are  divided  down  to  the  fascia  transver- 
salis,  which  is  cautiously  raised  from  the  peritoneum  at  the 
upper  end  of  the  wound,  where  it  is  less  dense  and  less 
firmly  attached,  and  a  small  opening  made  into  it,  through 
which  the  finger  or  a  large  grooved  director  can  be  passed, 
upon  which  it  is  divided  to  the  full  extent  of  the  wound. 
The  hand  of  an  assistant,  who  must  stand  on  the  opposite 
side  of  the  body,  is  then  introduced  into  the  wound  and 
the  peritoneum  raised  gently  upward  and  outward,  while 
the  operator  by  the  aid  of  the  finger  or  handle  of  the  scalpel 
separates  it  carefully  from  the  tissues  beneath;  when  the 
psoas  magnus  is  reached,  the  surgeon  will  then  know  the  ex- 
act location  of  the  artery.  If  the  external  iliac  be  first  felt,  it 
is  to  be  followed  upward  to  the  common;  when  the  common 
iliac  is  reached,  and  the  areolar  tissue  surrounding  it 
scratched  aside  by  the  finger  or  a  director,  the  needle  is 
passed;  the  one  with  the  adjustable  end  being  the  better. 

Dangers. — The  dangers  attending  this  operation  are  con- 
siderable. The  peritoneum  may  be  lacerated;  the  ureter 
included  in  the  ligature;  the  veins  punctured  by  the  needle. 
The  assistant  who  raises  the  membrane  should  keep  the 
fingers  closely  approximated,  using  both  hands,  if  necessary, 
and  being  careful  that  the  fingers  do  not  become  too  much 
flexed,  else  they  may  lacerate  it.  If  the  patient  struggle, 
vomit,  or  cough,  the  membrane  should  be  permitted  to  re- 
turn to  its  normal  site,  until  quiet  is  again  restored.  The 
traction  necessary  to  separate  and  elevate  it  cannot  be  made 
too  carefully,  and  it  is  better  if  it  be  done  during  the  acts 
of  expiration,  since  at  this  time  less  downward  pressure 
will  be  made  by  the  abdominal  contents;  large,  broad,  re- 
tractors are  sometimes  employed  for  this  purpose,  but  they 
are  much  less  reliable  than  intelligent  hands. 

The  ureter  passes  across  the  artery  at  the  point  of  bifur- 
cation; it  is  in  little  danger,  since  it  is  usually  raised  along 
with  the  peritoneum  and  its  subjacent  tissue.  The  veins 
can  be  avoided  by  always  remembering  to  pass  the  needle 
from  them.  This  will  be  somewhat  difficult  on  the  right 
side,  owing  to  the  large  venous  trunks  in  close  contact  with 
it.  If  the  vein  obscures  the  arterial  trunk,  pressure  upon 
it  below  the  point  to  be  ligatured  will  diminish  its  size. 

Fallacies. — The  external  may  be  mistaken  for  the  common 


LIGATION   OF   INTERNAL   ILIAC.  89 

iliac.  The  relation  of  the  sacro-vertebral  prominence  to 
the  vessel  should  settle  this  doubt.  The  ligature  may  be 
applied  too  near  the  bifurcation,  owing  to  the  difficulty  of 
finding  it,  on  account  of  obscure  light  and  the  intimate  re- 
lation of  the  vessels.     Gare  only  will  solve  this  uncertainty. 

Results. — This  vessel  has  been  ligatured  sixty-eight  times, 
with  sixteen  recoveries,  giving  a  rate  of  mortality  of  about 
seventy-seven  per  cent. 

Ligature  of  Internal  Iliac. — This  vessel  is  about  an  inch 
and  a  half  in  length,  extending  from  the  bifurcation  of  the 
common  iliac  downward  and  forward  to  near  the  upper 
border  of  the  great  sacro-sciatic  foramen. 

Methods  of  Operation. — Two  or  three  incisions  are  given 
with  a  view  of  reaching  this  vessel.  Either  of  the  incisions 
employed  in  the  ligature  of  the  common  iliac,  will  easily 
lead  to  it;  or  an  incision  five  inches  in  length,  parallel  with 
the  epigastric  artery,  or  a  semicircular  one  about  seven 
inches  in  length,  two  inches  to  the  left  of  the  umbilicus, 
with  its  convexity  outwards,  and  ending  just  external  to  the 
external  abdominal  ring. 

This  vessel  possesses  no  practical  linear  or  muscular 
guide,  other  than  it  lies  to  the  inner  side  of  the  psoas 
magnus. 

Plan  of  the  Relations  of  the  Internal  Iliac  Artery. 
In  front. 

Peritoneum. 
Ureter. 


Outer  side.  ( Internal 

Psoas  magnus. 


j  Internal  I 
1    Iliac.     S 

Behind. 


Internal  iliac  vein. 
Lumbo-sacral  nerve. 
Pyriformis  muscle. 

Operation. — The  tissues  are  successively  divided  as  in  the 
primative  iliac  in  the  line  selected  for  the  primary  incision; 
the  peritoneum  is  elevated  in  the  same  cautious  manner, 
the  connective  tissue  scratched  away,  and  the  ligature 
carried  from  within  outward,  taking  care  to  avoid  the 
ureter,  and  the  external  iliac  vein  as  it  lies  at  the  angle  of 
bifurcation  of  the  primative  iliac. 

Fallacies. — It  might  be   mistaken  for  the  external   iliac; 


go 


OPERATIVE   SURGERY. 


however,  this  can  be  quickly  rectified  if  the  course  of  the 
latter  be  considered. 

Results  of  the  Cases. — Eighteen  terminated  fatally;  making 
a  rate  of  mortality  of  about  seventy  per  cent. 

Ligature  of  the  Gluteal  Artery. — This  vessel  passes  out  of 
the  pelvis  at  the  upper  border  of  the  great  ischiatic  notch, 
above  the  pyriformis  muscle. 

Linear  guide  to  the  vessel  is  a  line  extending  from  the 
posterior  superior  spinous  process  of  the  ilium,  to  the  tro- 
chanter major  when  rotated  inward.  The  artery  is  beneath 
the  junction  of  the  upper  and  middle  thirds  of  this  line 
("A,"  Fig.  99). 


Fig.  99. 


Anatomically  it  lies  in  the  upper  border  of  the  notch, 
the  concavity  of  which  is  a  guide  to  it;  it  is  accompanied 
by  its  venae  comites,  and  is  covered  by  the  gluteus  maximus 
muscle. 

Operation. — Place  the  patient  on  his  abdomen,  with  the 
thigh  extended;  make  an  incision  five  inches  in  length  in 
the  course  of  the  line  indicated.  The  line  of  separation 
will  pass  between  the  fibres  of  the  gluteus  maximus, 
down   to   the  vessel;    liberate   it  from  its   accompanying 


LIGATION   OF   SCIATIC   AND   INTERNAL   PUDIC. 


91 


veins    and    pass    the   ligature    in    the    most    convenient 
manner  (Fig.  100). 

Fallacies. — It  might  be  mistaken  for   either  of  its  venae 
comites;    otherwise  no  fallacy  will 
occur. 

Results. — The  operation  itself  im- 
plies but  little  danger  to  the  pa- 
tient. 

Ligature  of  the  Sciatic  Artery. — 
This  vessel  escapes  from  the  pelvis 
below  the  pyriformis  muscle,  and 
passes  downward  in  the  interval 
between  the  tuberosity  of  the  ischi- 
um and  the  trochanter  major. 

Linear  guides  to  the  vessel  are  two 
in  number;  one  of  which  is  drawn 
parallel  with  the  preceding,  only 
about  an  inch  and  a  half  lower 
down.  A  second,  extending  from 
the  posterior  superior  spinous 
process  of  the  ilium  to  the  outer 
side  of  the  tuberosity  of  the  ischi- 
um.    (See  B,  Fig.  99.) 

Its  deep  muscular  guide  is  the  lower  border  of  the  pyri- 
formis, beneath  which  it  descends  from  the  pelvis. 

Contiguous  Anatomy. — It  is  covered  by  the  gluteus  maxi- 
mus;  the  sciatic  nerve  accompanies  it,  and  it  is  posterior  to 
the  pudic  artery. 

Operation. — An  incision  is  made  three  or  four  inches  in 
length  on  one  of  the  lines  indicated,  down  through  the 
fibres  of  the  gluteus  maximus,  the 
nerves  and  veins  are  pushed  aside,  and 
the  ligature  is  carried  around  it.  Care 
being  used  to  avoid  the  vein  which 
lies  to  its  outer  side.     (Fig.  loi.) 

Fallacies. — This  artery  might  be  mis- 
taken for  the  pudic  artery,  which  lies 
internal  to  it;  however,  the  direction 
taken  by  the  respective  vessels  should 
make  the  distinction  easy. 

Results. — The  prognosis  to  life  is  al- 
ways good  so  far  as  the  operation  itself  is  concerned. 

Ligature  of  the  Inter7ial  Pudic  Artery. — This  vessel  escapes 
from  the  pelvis  through  the  greater  sacro-sciatic  foramen 


Fig. 


92 


OPERATIVE   SURGERY. 


below  the  pyriformis  muscle,  lying  internal  to  the  sciatic 
artery;  then  enters  the  pelvis  through  the  lesser  sacro- 
sciatic  foramen,  and  runs  along  the  inner  surface  of  the 


Fig.  102. 

ramus  of  the  ischium  and  pubes,  till  it  divides  into  its  ter- 
minal branches. 

It  maybe  ligatured  in  two  situations:  (i)  At  the  greater 
sacro-sciatic  foramen;  (2)  in  the 
perineum.  In  the  first  situation 
the  incision  for  the  sciatic  is 
sufficient,  the  pudic  being  found 
internal  to  that  arterj',  and  lower 
down  accompanied  by  its  veins 
and  the  pudic  nerve.  In  the  per- 
ineum the  linear  guide  to  the 
operation  extends  from  the  arch 
of  the  pubes  to  the  inner  border 
of  the  tuber  ischii  (Fig.  102). 
The  artery  is  situated  about  an 
inch  and  a  quarter  above  the 
margin  of  the  tuber  ischii. 

Contiguous  Anatofuy. — It  runs 
along  the  outer  side  of  the  ischio- 
rectal fossa,  resting  upon  the 
obturator  internus  muscle,  covered  by  the  obturator  fascia, 
and  accompanied  by  the  pubic  veins  and  pudic  nerve. 


Fig. 


LIGATION   OF   EXTERNAL   ILIAC.  93 

Operation. — The  patient  is  placed  in  the  lithotomy  posi- 
tion and  an  incision  is  made  in  the  course  of  the  line 
indicated,  the  tissues  are  carefully  divided  down  to  the 
vessel,  which  is  then  isolated  from  its  veins  and  nerves  and 
tied  (Fig.  103).  If  care  be  not  taken  the  crus  penis  will  be 
cut.  The  introduction  of  a  sound  into  the  urethra  will  so 
positively  define  its  outlines  that  the  danger  of  cutting 
will  be  obviated. 

Ligature  of  the  Dor  sails  Penis. — This  maybe  tied  on  the 
dorsum  of  the  penis  by  making  an  incision  an  inch  in 
length  on  a  line  corresponding  to  the  centre  of  its  long 
axis.  It  is  superficial,  and  is  attended  by  its  veins  and 
nerves,  which  should  be  carefully  avoided  in  passing  the 
needle. 

Ligature  of  the  External  Lilac  Arteiy. — This  vessel  is  about 
four  inches  long  and  passes  obliquely  downward  and  out- 
ward, nearly  corresponding  to  a  line  drawn  from  the  left 
side  of  the  umbilicus  to  midway  between  the  anterior  su- 
perior spinous  process  of  the  ilium  and  the  S3'mphisis  pubis. 
It  is  ligated  at  about  the  middle  of  its  course.  It  has  no 
superficial  muscular  guide;  however,  the  psoas  magnus,  at 
the  inner  border  of  which  it  lies,  is  a  most  important  deep 
muscular  guide. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  External  Iliac  Artery. 

In  front. 

Peritoneum,  intestines. 

■VT  r  Spermatic  vessels. 

p  f'     J  Genital  branch.     Genito-crural  nerve. 

J  .     P  1  Circumflex  iliac  vein. 

°  ■    [Lymphatic  vessels  and  glands. 

Outer  side.  Inner  side. 

Psoas  magnus.  -I     ii'|™     [  External  iliac  vein  and  vas 

Iliac  fascia.  '  deferens  at  femoral  arch. 

Behind. 

External  iliac  vein. 
Psoas  magnus. 
Iliac  fascia. 

Operation. — Before  beginning  the  operation  evacuate  the 
contents  of  the  bladder  and  rectum  of  the  patient,  then 
place  him  in  a  recumbent  position,  with  the  thigh  slightly 
flexed.  A  curvilinear  incision  is  then  made,  with  the  con- 
vexity downward,   beginning   about   an   inch    and  a  half 


94 


OPERATIVE   SURGERY. 


above  Poupart's  ligament,  and  immediately  to  the  outer 
side  of  the  external  abdominal  ring,  and  terminating  on  a 
level  with,  but  about  two  inches  internally  to  the  anterior 
superior  spinous  process  of  the  ilium  (Fig.  104,  C).  The 
superficial  fascia,  aponeurosis  of  the  external  oblique,  the 
muscular  fibres  of  the  internal  oblique,  and  the  transversalii 
are  separately  divided  upon  a  grooved  director.  The  fascia 
transversalis  is  now  carefully  picked  up  with  the  thumb 
forceps,  and  a  small  opening  made  through  it,  into  which 


Fig.  104. 

the  director  is  inserted  and  the  fascia  divided.  The  peri- 
toneum and  its  subserous  tissue  are  then  carefully  raised 
from  the  iliac  fascia,  and  pressed  upward  and  inward 
until  the  outer  border  of  the  psoas  magnus  is  ascertained, 
when,  after  a  little  further  separation,  the  vessel  is  felt 
pulsating  at  its  inner  margin. 

The  condensed  areolar  tissue  constituting  its  sheath  is 
then  opened,  and  the  needle  careful!}'-  inserted  between  the 
vein  and  artery,  from  within  outward.  If  the  incision  be 
made  about  a  half  of  an  inch  above  Poupart's  ligament 
it  will  come  upon  the  iliac  fascia  without  coming  in  con- 


LIGATION  OF  EXTERNAL  ILIAC.  95 

tact  with  the  peritoneum,  since  it  is  reflected  upward  and 
downward  into  the  pelvis  a  little  above  this  point. 

Fallacies. — The  external  oblique  aponeurosis  may  be  mis- 
taken for  the  deep  layer  of  fascia.  The  muscular  fibres  of  the 
internal  oblique  will  then  be  mistaken  for  those  of  the  exter- 
nal oblique.  If,  howevc",  the  direction  of  the  fibres  of  the 
respective  muscles  be  recalled,  and  furthermore,  that  the 
external  oblique  has  no  muscular  fibres  in  this  situation, 
the  mistake  will  be  quickly  rectified.  The  fascia  transver- 
salis  may  be  mistaken  for  the  peritoneum;  this  fallacy  is 
easily  detected  by  following  it  downward,  when,  if  it  be  at- 
tached to  Poupart's  ligament,  or  passes  beneath  it,  it  can- 
not be  the  peritoneum,  and  must  therefore  be  the  transver- 


,.,#■ 


<  .  ^ 
M 
|j'^ 


Fig.  105. 

salis  fascia.  If  its  relations  to  the  previously  divided 
tissues  be  taken  into  account,  together  with  its  density  and 
opacity,  this  mistake  can  hardly  occur. 

The  iliac  fascia  may  be  mistaken  for  the  subserous  tissue, 
and  be  raised  along  with  the  peritoneum.  Under  such  cir- 
cumstances the  vessel  will  be  raised  upward  along  with  the 
peritoneum  and  iliac  fascia,  and  will  be  felt  pulsating  in 
the  roof  rather  than  the  floor  of  the  operation  wound.  This 
mistake  can  be  avoided  by  remembering  that  the  iliac  and 
psoas  muscles  are  covered  by  a  dense  fascia,  which  passes 
out  of  the  pelvis  beneath  the  Poupart's  ligament  and  is 
attached  to  it,  and  that  the  artery  does  not  lie  beneath 
it. 

If  an  irreducible  inguinal  hernia  exist,  or  the  vein  be 
adherent    to    the    artery,    then    much    difficulty  may  be 


96  OPERATIVE  SURGERY. 

experienced  in  properly  depositing  the  ligature  without 
injury  to  the  intestines  or  the  vein.  After  ligation  the 
wound  must  be  thoroughly  closed  by  carrying  the  sutures 
deeply  down  and  close  to  the  peritoneum,  the  superficial 
tissues,  integument,  and  fascia  being  united  separately.  If 
this  be  not  done  the  patient  will  be  exposed  to  the  danger 
of  the  occurrence  of  a  hernial  protrusion  due  to  the  weak- 
ening of  the  abdominal  walls.  This  is  a  precaution  which 
should  always  be  taken  in  operations  involving  the  separa- 
tion of  the  peritoneum. 

Results. — This  vessel  has  been  ligatured  169  times,  with 
61  deaths;  which  have  arisen  from  various  causes  connected 
either  with  the  operation  itself,  or  the  conditions  calling 
for  it. 

Ligature  of  the  Epigastric  Artery. — This  vessel  is  ligatured 
in  one  situation  only.  It  arises  from  the  lower  portion  of 
the  external  iliac  and  runs  upwards  toward  the  umbilicus, 
between  the  peritoneum  and  the  fascia  transversalis.  It 
lies  at  the  inner  border  of  the  internal  abdominal  ring. 

Linear  Guide. — A  line  extending  from  the  umbilicus  to 
the  midddle  of  Poupart's  ligament  corresponds  to  the 
course  of  the  vessel.  The  guide  to  the  first  incision  is  the 
middle  of  the  upper  border  of  Poupart's  ligament.  (See 
A,  Fig.  104.)  _        ^  

Operation. — An  incision  is  made  about  three  inches  in 
length  parallel  with  and  about  one  inch  above  Poupart's 
ligament.  The  various  layers  of  the  abdominal  wall  are 
then  divided  separately  upon  a  grooved  director  until  the 
fascia  transversalis  is  reached,  which  is  opened  over  the 
artery,  the  veins  separated  from  it,  and  the  ligature  prop- 
erly placed. 

The  wound  should  then  be  carefully  closed,  and  the  pa- 
tient kept  quiet  in  a  recumbent  posture  until  the  tissues 
are  firmly  united,  else  a  weak  point  in  the  abdominal  walls 
may  follow. 

Deep  Circumflex  Lliac. — This  vessel  may  be  secured  in  two 
positions:  (i)  At  the  internal  abdominal  ring;  (2)  near  the 
anterior  superior  spinous  process  of  the  ilium.  In  the  first 
it  may  be  tied  through  the  same  incision  as  the  epigastric. 
In  the  second  it  may  be  secured  through  an  incision  made 
parallel  to  Poupart's  ligament  and  just  above  it,  through 
the  various  tissues  anterior  to  the  transversalis  fascia, 
which  is  then  opened,  the  artery  isolated  and  tied. 

Ligature  of  the  Femoral  Artery. — The  femoral  artery  ex- 


LIGATION  OF  FEMORAL. 


97 


tends  from  Poupart's  ligament  to  the  lower  extremity  of 
Hunter's  canal,  at  the  junction  of  the  middle  and  lower 
thirds  of  the  thigh,  where  it  terminates  in  the  popliteal.  It  is 
ligatured  in  three  situations:  (i)  Just  below  Poupart's  liga- 
ment; (2)  at  the  apex  of  Scarpa's  triangle,  or  about  four 
inches  below  the  ligam'^nt;  (3)  at  its  lower  third,  or  in 
Hunter's  canal.  The  most  favorable  situations  are  at  the 
apex  of  Scarpa's  triangle  and  in  Hunter's  canal.  However, 
circumstances  often  arise  which  necessitate  its  being  tied, 
irrespective  of  the  stereotyped  situations. 

The   linear  guide  to    the  artery  throughout   its  whole 


Fig.  106. 


course  is  a  line  drawn  from  midway  between  the  anterior 
superior  spinous  process  of  the  ilium  and  the  symphysis 
pubes  to  the  inner  condyle  of  the  femur  (Fig.  106,  A). 

A  line  drawn  from  the  origin  of  the  adductor  longus  to 
the  insertion  of  the  adductor  magnus  tendon  into  the  in- 
ternal condyle  of  the  femur,  also  corresponds  to  the  femoral 
at  its  lower  third.     (See  Fig.  107.) 

The  Muscular  Guide. — The  sartorius  is  given  as  its  mus- 
cular guide;  the  artery  is  at  its  inner  border  in  the  upper 
third,  behind  it  in  its  middle,  and  at  its  outer  side  in  its 


98 


OPERATIVE   SURGERY. 


lower  third.     The  better  muscular  guide  to  the  lower  third 
is  the  inner  border  of  the  tendon  of  the  abductor  magnus. 
Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Femoral  Artery. 
In  front. 
Fascia  lata. 

Branch  of  anterior  crural  nerve. 
Sartorius  (middle  part). 
Long  saphenous  nerve. 
Aponeurotic  covering  of  Hunter's  canal  (lower  part). 


j  Femoral  1 
(  Artery.  \ 


Inner  side. 

Femoral  vein  (at  upper  part), 
Adductor  longus. 
Sartorius. 

Behind. 

Psoas  muscle. 

Profunda  vein. 

Pectineus  muscle. 

Adductor  longus. 

Femoral  vein  (middle  part). 

Adductor  magnus. 


Outer  side. 
Vastus  internus. 
Femoral  vein  (at  lower  part). 


LIGATION   OF  FEMORAL. 


99 


Operation. — First  situation  common  femoral.  The  vessel 
can  be  ligatured  immediately  below  Poupart's  ligament 
through  two  incisions;  one  made  in  the  long  axis  of  the 
vessel,  the  other  parallel  with  the  lower  border  of  the  liga- 
ment. (See  B,  Fig.  104.)  The  former  is,  however,  the 
better  method.  The  patient  is  placed  upon  his  back,  and 
the  thigh  flexed  and  rotated  outward.  The  pulsation  of 
the  artery  noted  by  the  finger,  when  an  incision  about  three 
inches  in  length  is  made  through  the  integument,  and  sub- 
cutaneous tissues  are  divided,  the  fascia  lata  is  divided  on  a 
director  in  the  usual  manner,  and  the  sheath,  which  is  of 


^  \>'' 


Ik 


much  density,  is  opened  and  the  needle  passed  from  with- 
in outward  (Fig.  108).  The  vein  will  be  noticed  at  its 
inner  side,  enclosed  in  a  common  sheath  with  it,  but  sepa- 
rated from  the  artery  by  a  fibrous  partition  (Fig.  109). 
The  attention  of  the  surgeon  should  be  directed  to  the 
pinkish  white  pulsating  vessel  rather  than  to  seeking  for 
the  vein.  If  the  attention  and  manipulations  be  directed 
toward  the  artery,  the  vein  will  remain  securely  within  its 
apartment.  The  lymphatic  glands  which  are  encountered 
are  drawn  aside. 

Second   situation:  At  tlie   apex  of  Scarpa's   triangle,  or 


lOO 


OPERATIVE   SURGERY. 


about  four  inches  below  Poupart's  ligament.  Tiie  saphe- 
nous vein  runs  along  the  inner  side  of  this  region;  its  loca- 
tion can  be  determined  by  pressing  above,  which  will  cause 
it  to  be  distended.  The  limb  is  placed  as  in  the  preceding 
operation,  and  an  incision  is   made  about  four  inches  in 


Fig.   109. 


length  along  the  inner  border  of  the  sartorius  muscle: 
divide  the  tissues  down  to  the  fascia  lata,  draw  the  sarto- 
rius to  the  outer  side,  and  the  sheath  of  the  vessel  will  be 
seen  with  the  pulsations  of  the  artery  beneath  it;  cau- 
tiously open  it,  and  pass  the  needle  from  within  outward. 
The  vein  lies  to  the  inner  side,  somewhat  more  posteriorly 
than  above  (Fig.  no). 


LIGATION    OF  FEMORAL 


lOI 


Third  situation:  or  in  Hunter's  canal.  Flex  the  thigh 
on  the  pelvis  and  the  leg  on  the  thigh,  with  thigh  rotated 
outward;  an  incision  is  then  made  along  the  outer  border 
of  the  tendon  of  the  adductor  magnus  (see  Fig.  io6,  A), 
about  four  inches  in  length,  down  through  the  integument 
and  fascia,  when  the  tendon  will  be  readily  felt.  If  the 
sartorius  be  in  the  way  it  should  be  drawn  to  the  outer 
side.  Any  intervening  soft  parts  are  pushed  aside,  which 
will  expose  the  fibrous  canal  in  which  the  artery  is  con- 
tained, the  fibres  of  the  adductor  magnus  with  the  inner 


Fig.  ho. 

border  of  the  vastus  internus.  The  canal  is  cautiously 
opened,  and  the  long  saphenous  nerve  is  seen  resting  upon 
the  vessel;  this  is  drawn  aside  and  the  needle  passed  from 
without  inward;  the  vein  now  being  located  posteriorly 
and  externally  (Fig.  iii).  The  vessel  can  be  ligatured  in 
this  situation  by  making  an  incision  of  a  similar  length  on 
the  linear  guide  above  (Fig.  io6);  it  is  not  so  easily  secured, 
however,  as  by  the  method  just  stated. 

Fallacies. — The  sartorius   may  be  mistaken  for  the  other 


I02 


OPERATIVE   SURGERY. 


muscles  lying  in  its  course.  If,  however,  it  be  recollected 
that  no  other  muscles  run  in  the  same  direction  on  the  an- 
terior surface  of  the  thigh,  and  that  it  is  superficial  through- 
out its  whole  course,  no  great  confusion  can  arise  from  this 
fallacy.  The  lymphatic  glands  that  lie  over  the  sheath  of 
the  vessel  in  the  upper  portion  of  its  course  may  be  mis- 
taken for  the  vessel  itself,  owing  to  their  color  and  to  the 
transmitted  pulsation.  These  are  irregular,  movable,  can 
be  raised  upward,  when  their  apparent  pulsation  will  cease. 
Moreover,  the  artery  is  beneath  the  fascia  lata,  and  they 
are  above  it. 

The  tendon  of  the  adductor  magnus  may  be  mistaken 
for  tendon  of  the  semimembranous  or  semitendinosus. 
This  mistake  will  be  avoided  if  the  tendon  be  traced  by 


Fig.   III. 


palpation  downward;  the  latter  will  pass  behind  the  inter- 
nal condyle,  while  the  former  will  be  found  inserted  into  it. 
Care  must  be  taken  in  ligaturing  it  at  the  apex  of  Scarpa's 
triangle  not  to  make  the  incision  too  low  down.  The 
width  of  the  hand  below  Poupart's  ligament  is  a  good 
practical  guide  to  its  apex.  In  ligaturing  it  in  Hunter's 
canal,  it  should  be  remembered  that  the  canal  is  located 
but  a  little  below  the  middle  third  of  the  thigh,  otherwise 
the  incision  will  be  made  too  low  down,  and  the  upper  por- 
tion of  the  popliteal  secured  instead. 

In  a  very  small  number  of  cases  (four)  the  femoral  has 
been  double;  in  a  like  number  it  passed  behind  instead  of  in 
front  of  the  thigh.  If  it  be  double,  the  portion  found  will 
be  smaller  than  normal,  and  the  object  for  which  the  liga- 
ture is  applied  will  not  be  accomplished.  If  the  vessel  be  not 


LIGATION  OF  PROFUNDA. 


103 


found  in  its  common  location  it  will  be  necessary  to  seek 
for  it  elsewhere.  Deep  pressure  may  enable  one  to  detect 
the  site  of  its  deviation. 

Results. — The  common  femoral  has  been  ligatured  eight 
times  for  aneurism,  with  a  rate  of  mortality  of  25  per  cent. 
The  superficial  femoral  has  been  tied  204  times,  with  a  mor- 
tality of  50  cases. 

Deep  Fe7jioral,  or  the  Profunda. — This  vessel  usually  comes 


Fig.  112. 

off  from  the  common  trunk  one  or  two  inches  below  Pou- 
part's  ligament.  It  may  arise  above  or  even  four  inches 
below  this  ligament.  There  is  no  known  manner  of  deter- 
mining its  site  prior  to  an  operation.  It  arises  from  its 
outer  side,  running  slightly  outward,  then  downward  and 
inward,  passing  behind  the  superficial  femoral,  accompa- 
nied by  its  vein,  which  lies  in  front  of  it  (Fig.  112). 


104 


OPERATIVE  SURGERY. 


Operation. — This  is  tied  through  the  same  incision  for  the 
ligation  of  the  common  femoral,  and  is  to  be  sought  for  at  its 
outer  side.  When  found  it  should  be  carefully  isolated,  in 
order  to  insure  a  sufficient  distance  from  the  giving  off  of 
its  circumflex  branches,  for  the  application  of  the  ligature. 
Fallacies. — It  may  arise  from  the  inner  or  back  portions 
of  the  common  femoral.  If  not 
found  in  the  usual  place,  it  should 
be  sought  after  in  these  situations. 

Ligature  of  the  Popliteal  Artery. — 
This  vessel  may  be  ligatured  in  two 
situations:  at  its  upper  and  lower 
portions.  It  is  continuous  with  the 
femoral,  beginning  at  the  junction 
of  the  middle  and  lower  thirds  of 
the  thigh,  at  the  termination  of 
Hunter's  canal,  and  passes  with  a 
slight  obliquity  downward  and  out- 
ward to  the  lower  border  of  the 
popliteus  muscle. 

Linear  Guide. — The  linear  guide 
begins  a  little  to  the  inner  side  of 
the  middle  of  the  upper  portion  of 
the  popliteal  space,  and  terminates 
below  between  the  heads  of  the  gas- 
trocnemius muscle,  passing  mid- 
way between  the  condyles  of  the 
femur.     (Fig.  113.) 

Muscular  Guide. — In  its  upper 
third  it  lies  to  the  inner  border  of 
the  semimembranosus;  at  its  lower 
midway,  between  the  heads  of  the 
gastrocnemius. 

Contiguous  Anatojny. — In  the  upper 
third  the  internal  popliteal  nerve  is 
more  superficial  than  the  vein  and 
artery.  The  vein  lies  in  close  contact  with  the  artery,  and 
between  it  and  the  nerve.  The  artery  is  the  innermost 
of  the  three,  is  the  most  deeply  situated,  resting  on  the 
posterior  surface  of  the  femur.  In  the  lower  third,  the 
nerve  is  still  the  most  superficial,  but  lies  upon  and  to  its 
inner  side.  The  vein  in  this  situation  is  to  its  inner  side, 
and  more  superficial  than  the  artery,  which  rests  upon 
the  popliteus  muscle.     This  vessel  should  not  be  tied  in  its 


Fig.  113. 


LIGATION   OF   POPLITEAL. 


105 


middle  third,  on  account  of  the  large  number  of  branches 
given  off  at  this  ooint,  together  with  its  contiguity  with 
the  knee-joint. 

Operation  in  the  Upper  Portion  (Fig.  [13,  B). — The  patient 
can  be  placed  upon  the  face;  or,  while  on  the  back  the  thigh 
can  be  well  flexed  and  rotated  outward.  Tlie  former  posi- 
tion is  more  convenient  for  the  surgeon,  but  is  objection- 
able on  account  of  safety  to  the  patient.  The  patient  may 
be  placed  on  the  side  corresponding  to  the  limb  to  be  oper- 
ated upon,  with  that  thigh  extended  and  the  opposite  one 


*f 


Fig.  114. 


Fig.  115. 


flexed  on  the  pelvis,  when  the  safety  and  comfort  of  both 
will  be  consulted. 

An  incision  is  made,  about  four  inches  in  length,  along 
the  inner  border  of  the  semimembranosus,  through  the  in- 
tegument and  fascia,  and  is  then  continued  downward  by 
separating  the  areolar  tissue  with  the  handle  of  the  scalpel 
or  fingers.  The  nerve  will  no  doubt  be  first  seen,  and 
when  pulled  outward  the  vein  will  be  found  lying  more 
deeply  and  internal  to  it;  if  this  be  now  carefully  isolated 
and  pulled  in  the  same  direction,  the  artery  will  be  seen  at 
its  inner  side,  which  must  be  separated  from  the  surround- 


io6 


OPERATIVE   SURGERY. 


ing  tissue,  and   the  needle   carried   from   without  inward 
(Fig.  114.) 

Operation  in  the  Lower  Portion,  Fig.  113,  C. — Make  an  inci- 
sion midway  between  the  heads  of  the  gastrocnemius, 
carefully  avoiding  the  external  saphenous  vein  and  nerve, 
which  escape  between  the  heads  of  that  muscle;  separate 
the  connective  tissue  with  the  handle  of  the  scalpel,  draw 
the  vein  and  nerve  to  the  inner  side,  and  pass  the  needle 
from  within  outward.  Its  lower  third  may  be  tied  below 
the  inner  condyle  of  the  tibia.  The  linear  guide  in  this 
situation  is  continuous  with  that  of  the  posterior  tibial 
(see  Fig.  117),  and  the  limb  should  be  placed  in  a  similar 
position  as  for  ligaturing  the  posterior  tibial.  (Fig.  115.) 
Fallacies. — The  tendon  of  the  semi- 
tendinosus  may  be  mistaken  for  the 
semimembranosus.  At  the  upper 
portion  the  semimembranosus  has  a 
large  fleshy  belly,  which  extends 
much  nearer  to  the  median  line  of 
the  popliteal  space  than  the  semiten- 
dinosus. 

Sometimes  there  are  two  popliteal 
veins,  one  on  either  side  of  the  vessel. 


Fig.  116. 


Fig.  117. — Transverse  Section,  Middle  Third. 

I.  Soleus.  2  and  3.  Gastrocnemius.  4.  Flexor  lon^s 
poUicis.  5.  Peroneus  longus  and  brevis.  6.  Extensor 
longus  pollicis.  7.  Extensor  com.  digitorum.  8.  Tibi- 
alis amicus.  9.  Tibialis  posticus.  lo.  Flexor  longus 
dig.  II.  Anterior  tibial  artery  and  venae  comites.  12. 
Anterior  tibial  nerve.  13.  Posterior  tibial  artery  and 
venae  comites.  14.  Posterior  tibial  nerve.  15.  Peroneal 
artery  and  venae  comites. 


LIGATION   OF  ANTERIOR  TIBIAL.  IO7 

Results. — It  is  seldom  ligatured  unless  it  be  ruptured, 
when  both  ends  must  be  tied.  Of  the  three  or  four  cases 
thus  reported,  all  terminated  unfavorably. 

Ligature  of  the  Anterior  Tibial  Artery. — It  arises  from  the 
popliteal,  just  below  the  lower  border  of  the  popliteus 
muscle,  passes  forward  between  the  bones  of  the  leg, 
above  the  interosseous  membrane,  then  downward  on  its 
anterior  surface  to  the  ankle  joint,  where  it  becomes  the 
dorsalis  pedis.  This  vessel  can  be  tied  in  three  situations: 
at  its  upper,  middle,  and  lower  thirds;  but  two,  the  middle 
and  lower,  are  more  than  sufficient  for  all  practical  pur- 
poses. 

The  lifiear  guide  of  the  vessel  is  drawn  from  the  inner 
border  of  the  head  of  the  fibula  to  midway  between  the 
malleoli.     (Fig.  116.) 

The  muscular  guide  is  the  outer  border  of  the  tibialis 
anticus  muscle.     (Fig.  117.) 

Cotitiguous  Anatomy. 

Plan  of  the  Relations  of  the  Anterior  Tibial  Artery. 

In  front. 
Integument,  superficial  and  deep  fasciae. 
Tibialis  anticus  (overlaps  it  in  upper  part  of  leg). 
Extensor  longus  digitorum  )  /         ,       ..    ,.  .  ..,  v 
Extensor  proprius  pollicis    [  (^^^'^^^P  '^  slightly). 
Anterior  tibial  nerve. 

Inner  side.  Outer  side. 

Tibialis  anticus.  Anterior  tibial  nerve. 

Extensor    proprius    pollicis        j  Anterior )        Extensor  longus  digitorum. 
(crosses    it  at    its    lower       '  Tibial.  )       Extensor  proprius  pollicis. 
part). 

Behiftd. 
Interosseous  membrane. 
Tibia. 
Anterior  ligament  of  ankle-joint. 

Operations:  Upper  Third. — The  great  depth  of  the  vessel 
in  this  situation  renders  the  tying  of  it  one  of  the  most 
difficult.  Unless  circumstances  demand  it,  the  ligaturing 
at  this  situation  should  not  be  attempted.  The  following 
figure  shows  the  deep  relations  of  the  vessel.  (Fig.  117^.) 
The  linear  and  muscular  guides  are  similar  to  those  of  the 
middle  third. 

Middle  Third. — The  artery  in  this  situation  lies  quite 
deep,  and  a  good  light  must  be  had  to  see  the  bottom  of 


io8 


OPERATIVE   SURGERY. 


the  operation  wound.  Place  the  patient  on  the  back  with 
the  thighs  extended,  the  leg  turned  inward,  and  the  foot 
forcibly  extended  to  mark  the  outlines  of  the  tibialis  anti- 
cus.  Make  an  incision  four  or  five  inches  in  length  on  the 
line  indicating  the  course  of  the  artery,  down  to  the  fascia, 
which  is  then  divided  on  a  director.  The  aponeurosis  is 
divided  along  the  line  of  apposition  between  the  tibialis 
anticus  and  the  extensor  longus  digitorum;  it  should 
likewise  be  divided   transversely  to   admit  of   the   wider 


Fig,  117a, — Transverse  Section,  Upper  Third. 

1.  Popliteus.  2  and  3.  Gastrocnemius.  4.  Soleus.  5.  Peroneus  longus.  6.  Exten- 
sor longus  dig.  7.  Tibialis  anticus.  8.  Tibialis  posticus.  9.  Posterior  tibial  artery 
and  venae  comites.  10.  Posterior  tibial  nerve.  11.  Anterior  tibial  artery  and  venae 
comites.    12.  Anterior  tibial  nerve. 


separation  of  these  muscles.  The  foot  is  now  flexed,  and 
with  the  finger  or  handle  of  the  scalpel  the  line  of  sepa- 
ration is  extended  directly  down  to  the  vessel;  separate  the 
surfaces  of  the  wound  with  a  spatula,  when  the  artery  with 
its  nerve  and  veins  will  be  seen,  the  nerve  being  in  front 
and  to  the  outer  side  ;  separate  the  veins,  draw  the  nerve 
aside  and  pass  the  ligature  from  without  inward  (Fig 
118.) 

Operation  at  the  Lower  TJiird. — With  the  limb  as  in  the 
preceding  instance,  extend  the  foot  to  mark  the  course  of 
the  tendon  of  the  tibialis  anticus;  make  an  incision  along 
the  external  border  of  the  tendon  on  the  linear  guide, 
about  three  inches  in  leno-th.     Divide  the  fascia  on  a  direc- 


LIGATION   OF   ANTERIOR   TIBIAL. 


109 


tor,  and  seek  with  the  finger  for  the  space  between  the 
tibialis  anticus  and  the  extensor  proprius  poUicis  which  has 
crossed  to  the  inner  side  of  the  vessel;  flex  the  foot,  sepa- 
rate these  muscles,  and  the  artery  will  be  seen  accompanied 
by  its  veins  and  nerve;  the  latter  lying  in  front  and  a  little 
to  the  outer  side;  isolate  the  artery,  and  place  the  ligature 
by  passing  from  without  inward. 

Fallacies. — The  outer  surface  of  the  head  of  the  tibia  may 


Fig.  118. 


Fig.  119. 


be  mistaken  for  the  head  of  the  fibula,  which  will  bring  the 
linear  guide  too  far  to  the  inner  side  of  the  leg,  and  cause 
the  incision  to  be  made  over  the  belly  of  the  tibialis  anti- 
cus muscle.  To  avoid  this  it  must  be  remembered  that  the 
head  of  the  fibula  is  more  posteriorly,  and  constitutes  the 
most  external  bony  prominence  at  this  joint. 

The  septum  between  the  tibialis  anticus  and  the  extensor 
longus  digitorum  may  be  indistinct  or  absent;  then  the 
outer  border  of  the  tibialis  can  be  determined,  (i)  by  for- 


no  OPERATIVE   SURGERY. 

cible  extension  of  the  tarsus;  (2)  by  determining  its  limits 
by  the  resistance  to  lateral  pressure;  (3)  the  line  indi- 
cating the  interspace  may  be  seen  at  the  lower  extremity 
of  the  cut  when  not  visible  above. 

The  vessel  may  be  rudimentary  or  absent;  it  may  run 
more  superficially  than  common.  So  long,  however,  as  it 
keeps  in  the  proper  line  its  pulsations  will  lead  to  its  de- 
tection. 

Ligature  of  the  Dorsalis  Pedis  Artery, — This  vessel  is  a 
continuation  of  the  anterior  tibial,  beginning  at  the  ankle- 
joint  and  passing  downward  between  the  metatarsal  bones 
of  the  great  and  second  toes.  It  is  tied  in  one  situation, 
and  on  a  line  which  is  a  direct  continuation  of  the  linear 
guide  to  the  anterior  tibial. 

The  Muscular  Guide  is  the  outer  border  of  the  tendon  of 
the  extensor  propriiis  pollicis  (Fig.  119). 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Dorsalis  Pedis  Artery. 
In  front. 

Integument  and  fascia. 

Innermost  tendon  of  Extensor  brevis  digitorum. 

Tibial  side.  Fibular  side. 

Extensor  proprius  pollicis.  J  Dorsalis  I        Extensor  longus  digitorum. 

(  Pedis,  i       Anterior  tibial  nerve. 

Behind. 

Astragalus.  "* 

Scaphoid. 

Internal  cuneiform, 
and  their  ligaments. 

Operation. — Extend  the  tarsus  and  forcibly  flex  the  great 
toe  to  make  prominent  the  tendon  of  the  extensor  proprius 
pollicis;  make  an  incision  about  three  inches  in  length 
along  its  inner  border,  commencing  from  the  bend  of  the 
ankle;  divide  the  fascia  on  a  director,  when  the  fleshy 
under  portion  of  the  flexor  brevis  digitorum  will  be  seen; 
this  should  be  drawn  outward  when  the  artery  and  its- 
satellite  veins  will  be  seen;  separate  the  artery  from  them, 
and  pass  the  needle  as  best  suits  the  convenience  of  the 
operator  (Fig.  120). 

Fallacy. — It  may  pass  outside  of  the  line  indicating  its 
proper  course. 


LIGATION   OF   POSTERIOR   TIBIAL. 


Ill 


Ligature  of  the  Posterior  Tibial  Artery. — It  is  an  artery  of 
considerable  size  which  comes  from  the  popliteal  at  the 
lower  border  of  the  popliteus  muscle,  passes  obliquely  to 
the  tibial  side  of  the  leg,  going  down  between  the  super- 
ficial and  deep  layers  of  muscles  to  a  point  midway  be- 
tween the  internal  malleolus  and  inner  tuberosity  of  the 


j1./4- 


Fig.  12a 


Fig. 


OS  calcis,  where  it  terminates  a  little  later  in  the  external 
and  internal  plantar  vessels.  It  may  be  ligatured  in  three 
situations:  at  its  middle  and  lower  thirds,  and  as  it  passes 
behind  the  inner  malleolus. 

The  linear  guide  of  this  vessel  is  drawn  from  the  middle 
of  the  popliteal  space  to  midway  between  the  inner 
malleolus  and  tuberosity  of  the  os  calcis.  This  guide  is  not 
a  feasible  one,  since,  to   reach    the  artery  by  cutting  upon 


112  .     OPERATIVE   SURGERY. 

it  necessitates  the  diversion  of  tlie  fibres  of  the  muscles 
of  the  calf  of  the  leg. 

Li?iear  guide  to  the  operation  is  made  by  drawing  a  line 
three  fourths  of  an  inch  behind  the  posterior  border  of 
the  tibia  in  the  upper  and  lower  thirds,  from  its  upper  to 
its  lower  extremity  (Fig.  121). 

The  Afuscular  Guide. — At  its  middle  third  it  lies  beneath 
the  soleus;  at  its  lower  third  to  the  outer  border  of  the 
flexor  longus  digitorum. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Posterior  Tibial  Artery. 
/«  front. 
Tibialis  posticus. 
Flexor  longus  digitorum. 
Tibia. 

Ankle-joint. 
Inner  side.  Outer  side. 

Posterior  tibial  nerve,  J  Posterior  I  Posterior  tibial  nerve, 

upper  third.  •    TibiaL   j  lower  two  thirds. 

Behind. 
Gastrocnemius. 
Soleus. 
Deep  fascia  and  integument. 

Operation  at  its  Middle  Third  (Fig.  122). — Place  the 
patient  on  the  back,  flex  the  leg  on  the  thigh  and  the 
thigh  on  the  pelvis,  so  the  leg  will  lie  on  the  outer  side. 
Make  an  incision  on  the  line  indicated  about  four  inches 
in  length;  divide  the  deep  fascia,  recognize  the  inner  border 
of  the  gastrocnemius,  beneath  which  will  be  seen  the  fibres 
of  the  soleus,  which  should  be  divided  on  a  director,  down 
to  the  pale  yellow  aponeurosis  on  its  under  surface;  sepa- 
rate the  fibres  of  the  soleus  and  make  an  opening  through 
its  aponeurosis  about  one  inch  from  the  inner  border  of 
the  tibia,  of  sufficient  size  to  expose  the  artery,  which  is 
found  beneath,  attended  by  its  veins  and  the  posterior 
tibial  nerve;  draw  the  nerve  to  the  outer  side,  separate  the 
vessel  from  the  veins  and  pass  the  needle  from  without 
inward. 

Operatio7i  at  the  Lower  Third  (Fig.  123). — Place  the  limb 
as  before;  make  an  incision  in  the  course  of  the  linear  guide 
about  three  inches  in  length;  divide  the  integument  and 
fascia  in  the  usual  manner;  separate  the  borders  of  the 
wound,  then  divide  the  aponeurosis  which  binds  do.wn  the 


LIGATION  OF  POSTERIOR  TIBIAL. 


113 


deep  layer  of  muscles  at  about  one  inch  from  the  posterior 
border  of  the  tibia,  push  aside  the  fat,  and  the  vessel  with 
its  nerve  and  veins  will  be  found  at  the  outer  border  of  the 
flexor  longus  digitorum.  Separate  the  vessel,  push  the 
nerve  to  the  outer  side  and  pass  the  needle  from  without 
inward. 

Operatio7i  between  the  os  calcis  and  internal  malleolus. 
Place  the  foot  on  the  outer  surface  and  make  a  curved 
incision  about  three  inches  in  length,  with  the  convexity 
uppermost,  and  its  centre  at  a  point  midway  between 
the    malleolus   and  the  inner   tuberosity  of  the   os  calcis. 


Fig.  123. 

(See  Fig.  121.)  Divide  the  fascia  and  the  internal  an- 
nular ligament  on  a  director,  using  caution  with  the 
latter,  since  the  artery  rests  beneath  it;  isolate  the  vessel 
from  the  veins  and  pass  the  needle  from  without  inward. 
In  passing  through  the  superficial  tissues  some  small 
brandies  of  the  long  saphenous  vein  may  be  divided,  unless 
caution  be  used.  In  old  people  both  these  and  the  vena 
comitis  often  become  varicose,  which  increase  the  difficulty 
of   finding   and    isolating  the  artery.     It  is  better  not  to 


114  OPERATIVE   SURGERY. 

attempt  to  ligature  it  in  this  situation  if  evidences  of 
varicosities  exist. 

Fallacies. — The  posterior  tibial  may  be  rudimentary  or 
absent.  In  either  instance  the  peroneal  is  usually  increased 
in  size. 

Ligature  of  the  Peroneal  Artery. — It  arises  from  the  pos- 
terior tibial  about  an  inch  below  the  popliteus  muscle,  passes 
obliquely  outward  to  the  inner  border  of  the  fibula,  along 
which  it  descends  to  the  lower  third  of  the  leg,  and  is  finally 
distributed  to  the  outer  side  of  the  ankle.  It  may  be 
ligatured  at  the  middle  third  of  the  leg. 

The  lifiear  guide  is  a  line  drawn  from  the  posterior  border 
of  the  head  of  the  fibula  to  the  external  border  of  the  tendo- 
achilles  at  its  insertion. 

Contiguous  Anatomy.     (See  Fig.  117.) 

Plan  of  the  Relations  of  the  Peroneal  Artery. 

In  front. 
Tibialis  posticus. 
Flexor  longus  pollicis. 
Outer  side. 
Fibula.  fi-^-'t 

BeJiind. 

Soleus.  ^ 

Deep  fascia. 

Flexor  longus  pollicis. 

Operation. — Extend  the  foot  and  make  an  incision  about 
four  inches  in  length  along  the  line  indicated,  parallel  with 
the  external  border  of  the  fibula.  Separate  the  attach- 
ments of  the  soleus  and  the  flexor  longus  pollicis  from  each 
other,  when  the  artery  will  be  found  at  the  inner  side  of  the 
flexor  longus  pollicis  close  to  the  fibula. 

Fallacies. — It  may  be  absent:  this  is,  however,  very  rare. 
It  may  be  overlooked,  and  the  posterior  tibial  found  in- 
stead. If  its  close  relation  to  the  fibula  be  remembered, 
this  mistake  will  not  occur. 

Ligature  of  the  Lfinonmiata  Artery. — The  innominata  artery 
arises  from  the  beginning  of  the  transverse  arch  of  the 
aorta  in  front  of  the  left  common  carotid,  passes  obliquely 
upward  and  outward  to  the  upper  border  of  the  right 
sterno-clavicular  articulation,  where  it  divides  into  the  right 
common  carotid  and  right  subclavian.  It  has  no  practical 
linear  or  muscular  guides. 


LIGATION   OF  INNOMINATA. 


115 


Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Innominate  Artery. 

In  front. 
Sternum. 

Sterno-hyoid  and  Sterno-thyroid  muscles. 
Remains  of  thymus  gland. 

Left  innominate  and  right  ii  ferior  thyroid  veins. 
Inferior  cervical  cardiac  branch  from  right  pneumogastric  nerve. 


Right  side. 
Right  vena  innominata. 
Right  pneumogastric  nerve. 
Pleura. 


'  Innominate  i 
Artery.     ( 

Behind. 
Trachea. 


Left  side. 
Remains  of  thymus. 
Left  Carotid. 


Operations. — Numerous  incisions  have  been  given  for 
gaining  access  to  the  vessel.  The  one  which  is  best  cal- 
culated to  afford  the  requisite  amount  of  room  was  em- 
ployed   by   the    late   Valentine    Mott    (Fig.    124).      Place 


^^^ 


Fig.  124. 

the  patient  on  the  back,  with  the  shoulders  somewhat 
raised  and  the  head  turned  to  the  opposite  side.  An 
incision  was  then  made  three  inches  in  length,  extending 
along  the  upper  border  of  the  clavicle  to  opposite  the 
centre  of  the  epi-sternal  notch.  This  is  joined  by  another 
of  a  similar  length  directed  along  the  anterior  portion  of 


Il6  OPERATIVE   SURGERY, 

the  sterno-mastoid  muscle.  This  triangular  flap,  consisting 
of  the  integument,  superficial  fascia,  and  platysma,  is  turned 
upward  and  inward.  The  portions  of  the  sterno-cleido- 
mastoid,  corresponding  to  the  horizontal  incision,  and  the 
sterno-hyoid  and  sterno-thyroid  muscles,  are  divided  on  a 
director  and  turned  aside.  The  inferior  thyroid  veins,  if 
they  now  come  into  view,  must  be  carefully  drawn  aside, 
the  deep  cervical  fascia  is  carefully  torn  or  cut  through, 
when  the  sheath  of  the  common  carotid  artery,  pneumogas- 
tric  nerve,  and  internal  jugular  vein  is  brought  into  view. 
Open  it,  draw  the  vein  and  nerve  to  the  outer  side,  and 
follow  the  carotid  down  to  the  subclavian,  the  origin  of 
which  should  be  exposed.  The  upper  portion  of  the 
innominata  is  then  to  be  separated  from  its  important 
connections  by  the  finger  or  a  blunt  director;  the  left  vena 
innominata  is  depressed,  and  the  right  vena  innominata, 
right  internal  jugular,  and  pneumogastric  nerve  are  carried 
to  the  right,  and  then  the  aneurismal  needle  is  passed  from 
below  upAvard  and  from  behind,  forward  and  inward,  in 
close  contact  with  the  vessel. 

Fallacies. — If  the  innominata  be  shorter  than  usual,  the 
lower  extremity  of  the  common  carotid  may  be  tied  instead. 
If  the  aorta  arches  to  the  right  side,  the  innominata  will  be 
on  the  left  side,  instead  of  the  right. 

The  necessity  of  treating  all  the  veins  and  the  pleura 
with  most  judicious  care  is  emphasized  by  the  knowledge 
of  the  fact  that  nearly  all  the  fatal  cases  thus  far  have  died 
from  pleuris}''  or  secondary  hemorrhage. 

Results. — This  vessel  has  been  ligatured  sixteen  times, 
with  one  recoverj\ 

Ligature  of  the  Subclavian  Artery. — This  vessel  can  be 
ligatured  in  three  situations:  (i)  Between  the  inner  border 
of  the  scalenus  anticus  and  its  origin;  (2)  behind  the  sca- 
lenus; (3)  between  its  termination  at  the  lower  border  of 
the  first  rib  and  the  outer  border  of  the  scalenus  anticus. 

Ligature  of  the  First  Portion^  Left  Side. — This  portion  has 
no  definite  linear  or  muscular  guide.  The  inner  border  of 
the  scalenus  anticus  is  of  use  in  leading  to  and  limiting  its 
extent.  Owing  to  its  origin  from  the  arch  of  the  aorta  it 
is  of  great  depth,  almost  beyond  the  reach  of  a  ligature; 
while  its  close  relation  to  very  important  structures,  injury 
to  which,  of  itself,  maybe  more  grave  than  the  condition  for 
which  the  vessel  is  tied,  render  it  exceedingly  difficult  to 
perform  and  of  questionable  expediency. 


LIGATION   OF  SUBCLAVIAN.  Ii; 

Contiguous  Anatomy. 
Plan  of  Relations  of  First  Portion  of  Left  Subclavian  Artery. 

In  front. 
Pleura  and  left  lung. 

Pneumogastric,  cardiac,  and  phrenic  nerves. 
Left  carotid  artery. 

Left  internal  jugular  and  innominate  veins. 
Sterno-thyroid,  Sterno-hyoid,  and  Sterno-mastoid  muscles. 
Inner  side.  Outer  side. 

a:sophagus.  j  Left  Subclavian  Artery,  j  Pleura. 

Trachea.  "(  First  Portion.  J 

Thoracic  duct. 

Behind. 
CEsophagus  and  thoracic  duct. 
Inferior  cervical  ganglion  of  sympathetic. 
Longus  colli  and  vertebral  column. 

Operation. — Place  the  patient  on  the  back  with  the  head 
extended  and  turned  to  the  opposite  side;  the  left  shoul- 
der should  be  well  depressed;  make  an  incision  three 
inches  and  a  half  in  length  along  the  inner  border  of  the 
sterno-cleido-mastoid  down  to  the  sternum;  another  two 
inches  and  a  half  in  length  along  the  inner  extremity  of  the 
clavicle,  meeting  the  former  near  the  trachea.  It  is  seen 
that  this  incision  is  substantially  the  same  as  for  the  liga- 
turing of  the  innominata  artery.  The  flap,  consisting  of 
the  integument,  superficial  fascia,  and  platysma,  is  turned 
aside,  one  half  of  the  clavicular  portion  of  the  sterno-mastoid 
and  its  whole  sternal  portion  are  then  divided  on  a  direct- 
or, bringing  into  view  the  sterno-hyoid,  sterno-thyroid  and 
to  the  outer  side  the  omo-hyoid.  The  sterno-thyroid  and  hy- 
/oid  should  be  divided  with  great  care,  after  being  liberated 
from  the  fascia  which  covers  them.  The  inner  edge  of  the 
scalenus  anticas  muscle  is  now  sought  for;  when  found  it 
will  guide  the  finger  directly  to  the  vessel.  The  impor- 
tant contiguous  structures  are  now  drawn  in,  pressed  away 
from  the  artery,  using  great  caution  to  avoid  the  thoracic 
duct,  which  will  be  in  the  line  of  search,  and  the  needle 
carefully  passed  from  before  backward.  The  great  depth 
of  the  vessel  will  make  it  exceeding  difficult  to  pass  the 
needle,  which  should  be  the  one  with  the  adjustable  ex- 
tremity. 

Results. — Tied  by  Dr.  J.  Kearney  Rogers,  1845;  patient 
died  from  secondary  hemorrhage  on  the  fifteenth  day. 

Ligature  of  First  Portion,  Right  Side. — The  inner  border 
of  the  anterior  scalenus  leads  to  it  upon  this,  the  same  as 
upon  the  left  side. 


Ii8 


OPERATIVE   SURGERY. 


Contiguous  Anatomy. 
Plan  of  Relations  of  First  Portion  of  Right  Subclavian  Artery. 

In  front. 
Clavicular  origin  of  Sterno-mastoid. 
Sterno-hyoid  and  Sterno-thyroid. 
Internal  jugular  and  vertebral  veins. 
Pneumogastric,  cardiac,  and  phrenic  nerves. 

Beneath, 

j  Right  Subclavian  Artery,  I  Pleura. 

\  First  Portion.  J 

Behind. 
Recurrent  laryngeal  nerve. 
Sympathetic. 
Longus  colli. 
Transverse  process  of  seventh  cervical  or  first  dorsal  vertebra. 

Operation. — The  position  of  the  patient,  primary  incisions, 
and  dissection  are  substantially  the  same  as  the  preceding. 


Fig.  125. 


LIGATION  OF   SUBCLAVIAN. 


119 


The  internal  jugular  should  be  pressed  aside  and  the  needle 
passed  from  below  upward  and  from  behind  forward, 
carefully  avoiding  the  pleura,  recurrent  laryngeal,  and 
phrenic  nerves.  The  ligature  of  the  vertebral  and  internal 
mammary  at  the  same  time  will  lessen  the  danger  of  secon- 
dary hemorrhage. 

Fallacies. — This  vessel  may  arise  from  the  arch  of  the 
aorta,  when  it  will  be  more  deeply  situated,  often  passing 
behind  the  oesophagus  or  between  it  and  the  trachea. 

Results. — Has  been  ligatured  thirteen  times;  all  the  cases 
proved  fatal,  of  which  eight  died  of  hemorrhage. 

Ligature  of  the  Second  atid  Third  Portions. — The  linear 
guide  to  the  operation  is  drawn  just  above  the  upper  border 
of  the  clavicle,  extending  between  the  posterior  border  of 


Fig.  126. 


the  sterno-cleido-mastoid  and  the  anterior  border  of  the 
trapezius,  and  should  be  about  four  inches  in  length.    (Fig. 

125.) 

Miiscidar  Guides  to  the  Artery. — This  vessel  has  no  super- 
ficial muscular  guide.  The  deep  muscular  guide  is  the 
outer  border  of  the  scalenus  anticus.  The  posterior  belly  of 
omo-hyoid,  while  not  in  close  contact  with  it,  serves  an  im- 
portant purpose  in  directing  the  attention  of  the  surgeon 
towards  it.  The  outer  border  of  the  scalenus  anticus  is  well 
indicated  by  the  posterior  border  of  the  sterno-cleido-mas- 


120  OPERATIVE   SURGERY. 

toid,  provided  the  latter  muscle  be  not  uncommonly  devel- 
oped. The  junction  of  the  inner  two  inches  of  the  clavicle 
with  its  outer  portion  is  a  far  more  unvarying  indication  of 
the  approximate  deep  location  of  its  outer  border  than  the 
former. 

The  tubercule  on  the  first  rib  into  which  the  scalenus  an- 
ticus  is  inserted  is  the  direct  guide  to  the  vessel,  the  artery 
being  directly  behind  it.     (Fig.  126.) 

Contiguous  Anatomy  of  Third  Portion. 

Relations  of  Third  Portion  of  Subclavian  Artery. 

In  front. 
Cervical  fascia. 

External  jugular,  supra-scapular,  and  transverse  cervical  veins. 
Ascending  branches  of  cervical  plexus. 
Subclavian  muscle  and  supra-scapular  artery  and  clavicle. 

Above.  Below, 

Brachial  plexus.  j  ^^erv  \  TiXiX.  rib. 

Omo-hyoid.  1  ) 

Behind. 
Scalenus  medius. 

Operation  :  Third  Portion. — Place  the  patient  on  the  back 
with  the  shoulders  elevated  from  the  table,  head  turned 
backward  and  to  the  opposite  side.  Draw  the  shoulder  of 
the  corresponding  side  firmly  downward  and  retain  it  in 
that  position.  Compress  the  external  jugular  vein  above 
the  clavicle  long  enough  to  cause  its  distension,  thereby  in- 
dicating its  exact  situation.  The  integument  is  then  drawn 
evenly  downward  and  incised  upon  the  clavicle,  which  will, 
when  allowed  to  retract,  carry  the  incision  upward  to  its 
proper  situation — one  half  inch  above  the  clavicle.  The 
superficial  fascia  and  platysma  are  then  divided  upon  a 
director,  being  careful  not  to  sever  the  external  jugular, 
which  can  be  either  pulled  aside  or  divided  between  two 
ligatures.  The  supra-scapular  and  transverse  cervical  veins 
should  be  treated  in  the  same  manner.  The  omo-hyoid  is 
now  sought  for  and  drawn  upward  if  necessary,  and  the 
supra-scapular  artery  avoided.  The  deep  cervical  fascia  is 
torn  asunder  by  the  finger-nail  or  a  director  and  the  outer 
border  of  the  scalenus  anticus  felt  for  on  a  line  with  the 
outer  border  of  the  sterno-cleido-mastoid,  if  it  has  not  been 
divided;  if  so,  it  should  be  located  as  described  under  the 
head  of  "  Muscular  Guides."    If  the  head  be  turned  smartly 


LIGATION  OF  SUBCLAVIAN. 


121 


to  the  opposite  side  the  scalenus  anticus  will  be  made  tense 
and  more  prominent.  When  found  it  should  be  followed 
downward  to  its  insertion,  when  the  finger  will  rest  upon 
the  tubercle  of  the  first  rib,  immediately  behind  which  the 
pulsation  of  the  artery  will  be  felt.  The  vessel  is  now  care- 
fully exposed  and  the  neodle  passed  from  before  backward. 
(Fig.  127.)  Great  caution  should  be  taken  not  to  interfere 
with  the  subclavian  vein,  which  lies  in  front  of,  and  on  a 
lower  plane  than  the  artery. 

Fallacies. — The  sterno-cleido-mastoid  may  have  an  un- 
usual breadth  of  origin  from  the  clavicle,  thereby  causing 
the  incision  to  be  made  too  far  posteriorly.     The  clavicular 


Fig.  127. 


measurement  will  prevent  this  error.  The  tubercle  on  the 
anterior  surface  of  a  transverse  process  of  one  of  the  lower 
cervical  vertebra  may  be  mistaken  for  the  tubercle  of  the 
first  rib.  This,  however,  is  easily  rectified  by  remembering 
that  the  rib  is  located  downward  and  backward,  that  no 
contiguous  pulsation  is  found,  and  that  the  outline  of  the 
scalenus  anticus  is  absent.  The  tubercle  may  be  absent, 
when  the  muscle  inserted  into  the  rib  must  be  relied  upon. 
The  artery  may  be  in  front  of  the  tubercle  and  the  vein 
behind.  The  pulsation  as  well  as  the  anatomical  appear- 
ances will  determine  the  interchange  of  situation.  The 
inner  cord  of  the  brachial  plexus  may  be  mistaken  for  the 
artery.  A  little  attention  to  the  distinctive  physical  char- 
acteristics between  nerves  and  arteries  will  quickly  settle 
this  doubt. 


122  OPERATIVE   SURGERY. 

Results. — Two  hundred  and  fifty-one  cases  tabulated,  of 
which  one  hundred  and  thirty-four,  or  fifty-three  per  cent, 
died. 

Ligature  of  the  Second  Portion. — All  muscular  and  linear 
guides  are  practically  similar  to  those  of  the  preceding. 

Contiguous  Anatomy. 
Plan  of  Relations  of  Second  Portion  of  Subclavian  Artery. 

In  front. 

Scalenus  anticus. 
Phrenic  nerve. 
Subclavian  vein. 

Above,  Below. 

Brachial  plexus.  \  ^SnTpon^on'^-  \  Pleura. 

Behind. 
Pleura  and  Middle  Scalenus, 

Operation. — The  proceedings  essential  to  arrive  at  the 
proper  site  in  this  instance  are  not  varied  from  those  given 
for  the  third  portion  until  the  outer  border  of  the  scalenus 
anticus  is  well  determined;  the  phrenic  nerve  and  sub- 
clavian vein  should  then  be  pushed  aside  and  the  muscle 
divided  (see  Fig.  127),  when  the  retraction  of  its  fibres  will 
expose  the  portion  to  view.  The  needle  is  then  passed  as 
before,  closely  hugging  the  artery,  to  avoid  the  pleura  be- 
low and  posteriorly. 

Fallacies. — The  vessels  may  be  transposed. 

Results. — Thirteen  cases  reported,  of  which  nine,  or  sixty- 
nine  per  cent,  were  lost. 

The  subclavian  should  always  be  tied  in  the  third  portion 
when  possible;  if  impossible,  the  second  should  be  selected. 
The  ligature  of  the  first  portion  is  unwarranted  in  view  of 
the  results  heretofore  gained. 

Ligature  of  the  Vertebral  Artery — This  artery  arises  from 
the  first  portion  of  the  subclavian  and  passes  directly  up- 
ward along  the  anterior  surface  of  the  vertebral  column 
to  the  transverse  process  of  the  sixth  cervical  vertebra.  It 
may  be  ligatured  in  three  situations:  (i)  Before  entering 
the  vertebral  canal;  (2)  between  the  atlas  atid  axis;  (3) 
between  the  atlas  and  the  occipital  bone.  The  first  situa- 
tion, however,  is  sufficient  for  all  practical  purposes. 

The  linear  guide  to  the  artery  is  drawn  from  the  junc- 
tion of  the  inner  fourth  with  the  outer  three  fourths  of  the 


LIGATION   OF   VERTEBRAL   AND   INT.    MAMMARY.      1 23 

clavicle,  to  the  posterior  border  of  the  mastoid  process. 
The  deep  guide  is  the  tubercle  of  the  transverse  process  of 
the  sixth  cervical  vertebra,  and  the  space  between  the  bor- 
ders of  the  longus  colli  and  the  scalenus  anticus. 

Contiguous  Anatomy. 

In  front. 

Internal  jugular  vein  and  its  sheath. 

Aponeurosis  between  longus  colli  and  scalenus  anticus. 

Superior  thyroid  artery. 

Vertebral  vein. 

Outer  side.  j  Vertebral )  Inner  side. 

Scalenus  anticus.  1  Artery.    (  Longus  colli. 

Behind. 
Vertebral  column. 

Operation. — The  head  should  be  turned  to  the  opposite 
side  and  an  incision  about  three  inches  and  a  half  in  length 
made  along  the  anterior  border  of  the  sterno-cleido-mas- 
toid,  terminating  at  the  upper  border  of  the  sternum. 
The  fascia  and  the  connections  between  the  sterno-mastoid 
and  sterno-hyoid  are  divided  and  these  muscles  separated, 
which  exposes  the  common  sheath  of  the  internal  jugular 
vein,  common  carotid  artery,  and  pneumogastric  nerve. 
This  sheath  is  now  carefully  separated  from  its  connections 
to  the  sterno-thyroid  and  longus  colli  muscles  and  drawn 
outward.  The  parts  are  now  relaxed  by  raising  the  head, 
the  inferior  thyroid  artery  displaced,  and  the  aponeurosis 
covering  the  vessel  torn  through,  the  vein  pushed  aside,  and 
the  ligature  deposited  from  within  outward. 

Results. — This  vessel  has  been  tied  eight  or  ten  times,  and 
so  far  as  the  operation  itself  is  concerned  no  ill  results  are 
reported. 

Ligature  of  the  Internal  Mammary  Artery. — The  internal 
mammary  arises  from  the  first  portion  of  the  subclavian. 
It  descends  behind  the  internal  jugular  and  subclavian 
veins  to  the  posterior  wall  of  the  chest,  resting  upon  the 
costal  cartilages  about  one  half  inch  from  the  margin  of 
the  sternum.  It  may  be  ligatured  in  any  of  the  upper  in- 
tercostal spaces. 

Lifiear  Guide  to  the  Artery. — About  one  half  inch  to  the 
outer  side  of  the  sternum  is  a  fair  indication  of  its  locality. 
It  has  no  muscular  guide. 

Operation. — Make  an  incision  two  inches  in  length  along  the 


124  OPERATIVE  SURGERY. 

upper  border  of  the  costal  cartilages  and  rib.  The  integu- 
ment, fascia,  and  pectoralis  major  muscle  are  divided  down 
to  the  intercostal  muscles.  Beneath  the  internal  intercostal 
muscle,  surrounded  by  the  connective  tissue,  the  artery,  ac- 
companied by  the  venae  comites,  will  be  found  The  vessel 
is  isolated,  and  the  needle  carefully  passed  to  avoid  pene- 
trating the  pleura.  If  the  vessel  be  tied  in  the  upper  inter- 
costal spaces  a  single  vein  will  attend  it. 

Ligature  of  the  I?iferior  Thyroid. — This  vessel  arises  from 
the  thyroid  axis,  passes  in  a  somewhat  irregular  course  up- 
ward and  inward  behind  the  sheath  of  the  common  caro- 
tid and  internal  jugular  vein  to  the  thyroid  gland. 

The  linear  guide  to  the  operation  is  along  the  anterior 
border  of  the  sterno-mastoid,  as  in  ligaturing  the  common 
carotid.  The  body  of  the  fifth  cervical  vertebra  opposite  to 
which  it  enters  the  gland  is  an  approximate  bony  guide 
to  the  vessel. 

Contiguous  Anatomy. — In  front  the  common  carotid  sheath 
and  its  contents  and  the  sympathetic  nerve  on  the  inner 
side;  on  the  left,  the  recurrent  laryngeal  and  the  oesopha- 
gus; if  low  in  the  neck,  carefully  avoid  the  thoracic  duct. 
The  respective  tissues  are  pulled  aside  and  the  needle 
passed.  No  dangers  attend  the  ligaturing  other  than  those 
incurred  by  the  manipulation^necessary  to  arrive  at  the 
vessel. 

Ligature  of  the  Axillary. — This  vessel  begins  at  the  lower 
border  of  the  first  rib  and  extends  to  the  lower  border  of  the 
tendon  of  the  latissimus  dorsi.  It  may  be  tied  in  three 
situations:  (i)  Above  the  pectoralis  minor;  (2)  behind;  (3) 
below  that  muscle.  The  first  and  last,  however,  are  the 
only  ones  at  which  the  vessel  can  be  practically  secured. 

First  Portion. — There  is  no  linear  guide  to  the  vessel. 
The  linear  guide  to  the  operation  is  located  about  one  half 
inch  below  the  lower  border  of  the  clavicle,  extending 
from  within  an  inch  or  so  of  the  sternal  extremity,  outward 
three  or  four  inches. 

The  muscular  guides  are  superficial  and  deep.  The  former 
is  the  space  between  the  border  of  the  deltoid  and  pectoralis 
major  muscles.  The  latter  is  the  pectoralis  minor;  its 
upper  border  corresponding  to  the  first  portion,  etc.,  etc., 
as  before  stated. 


LIGATION   OF  AXILLARY. 


I2S 


Contiguozis  Anatomy. 

Relations  of  the  First  Portion  of  the  Axillary  Artery. 
hi  fro7it. 

Pectoralis  major. 

Costo-coracoid  membrane. 

Subclt-vius. 

Cephalic  vein. 


Outer  side. 
Brachial  plexus. 


I  Axillary  ) 
■<  Artery.  > 
I  First  portion,  j 


Inner  side 
Axillary  vein. 


Behind. 
First  Intercostal  space,  and  Intercostal  muscle. 
First  serration  of  Serratus  magnus. 
Posterior  thoracic  nerve. 

In  this  situation  the  artery  lies  very  deeply,  and  it  is  bet- 
ter, if  possible,  to  ligature  the  third  portion  of  the  subclav- 
ian. 


n/flj/jniiT'''^'' 


••=^*^(ri L. 


Fig.  128. 

Operation  (Fig.  128). — Place  the  patient  upon  the  back  with 
the  head  turned  to  the  opposite  side;  raise  the  shoulder 
and  carry  the  arm  from  the  side  of  the  chest  somewhat. 
Make  an  incision  about  four  inches  in  length  on  the  line 
given,  down  through  the  integument,  fascia,  andplatysma; 
separate  the  fibres  of  the  pectoralis  major,  or  divide  them 
the  full  length  of  the  wound;  tear  apart  the  underlying 
fascia,  when  the  pectoralis  minor  muscle  will  be  brought 
in  view;  bring  the  arm  to  the  side  to  relax  it,  then  draw 
it  to  the  outer  side;    displace  the  areolar  tissue  carefully 


126 


OPERATIVE   SURGERY. 


with  the  finger  or  a  director,  when  the  vein  will  be  seen, 
which  should  be  carried  upward  and  outward  with  a 
blunt  hook,  and  the  artery  will  be  noticed  beneath  and 
above  it,  in  close  contact  with  the  inner  cord  of  the  brachial 
plexus,  which  lies  to  its  outer  side  and  above.  The  needle  is 
then  passed  from  below  upward.  The  cephalic  vein  which 
empties  into  the  axillary  vein  should  be  cautiously  avoided, 
as  it  passes  between  the  borders  of  the  pectoral  and  deltoid 
muscles  to  its  termination. 

Fallacies. — The  inner  cord  of  the  brachial  plexus  may  be 
mistaken  for  the  artery.  Before  tightening  the  ligature 
pressure  should  be  made  upon  the  vessel,  and  the  effect 
upon  the  radial  pulse  noted. 

The  vessel  may  be  reached  by  making  an  incision  be- 


FiG.  129. 


tween  the  borders  of  the  deltoid  and  pectoral  muscles  about 
three  inches  in  length,  which  shall  connect  with  the  one 
previously  made  below  the  lower  border  of  the  clavicle. 
The  fat  and  cellular  tissue  can  then  be  removed  or  dis- 
placed as  in  the  previous  instance. 

Results. — No  definite  records  are  given  of  the  results  of 
the  operation. 

Ligature  in  the  Third  Portia  ft. — Linear  guide  to  the  artery  is 
a  line  extending  upward  into  the  axilla  corresponding  to  the 
junction  of  its  anterior  and  middle  thirds.     (Fig.  129.) 


LIGATION  OF  BRACHIAL. 


127 


Muscular  Guide. — The  inner  border  of  the  coraco-brachia- 


lis. 


Contiguous  Anatomy. 

Relations  of  the  Third  Portion  of  the  Axillary  Artery. 

In  front. 
Integument  and  fascia. 
Pectoralis  major. 


Outer  side. 
Coraco-brachialis. 
Median  nerve. 
Musculo-cutaneous  nerve. 


Inner  side. 
Ulnar  nerve. 
I  Artery.  \  Internal  cutaneous  nerve. 

Axillary  vein. 


Behind. 
Subscapularis. 

Tendons  of  latissimus  dorsi  and  teres  major. 
Musculo-spiral  and  circumflex  nerves. 


130). — The  arm  should  be  adducted  and 
Make 


Operation  (Fig. 
rotated  outward, 
an  incision  three  inches 
in  length  along  the  inner 
border  of  the  coraco-bra- 
chialis in  line  of  the 
arterial  pulsation,  ob- 
serving that  its  centre 
be  above  the  fold  of  the 
axilla;  cautiously  divide 
the  tissue  upon  a  direct- 
or, drawing  the  median 
nerve  to  the  outer,  and 
the  veins  to  the  inner 
side;  pass  the  needle 
from  within  outward.  ^'°'  ^3°- 

Fallacies. — Large  branches  may  be  given  off  at  this 
situation,  which  will  confuse  the  operator.  Pressure  upon 
the  vessel  prior  to  the  tightening  of  the  ligature  will  deter- 
mine the  influence  upon  the  circulation  beyond. 

Results. — The  operation  implies  in  itself  no  particular 
danger  to  the  patient. 

Ligature  of  the  Brachial  Artery. — The  brachial  artery  ex- 
tends from  the  lower  border  of  the  tendon  of  the  latis- 
simus dorsi  to  about  one  inch  below  the  bend  of  the  elbow 
joint. 

The  linear  guide  is  drawn  from  the  junction  of  the  middle 


128 


OPERATIVE  SURGERY. 


and  anterior  thirds  of  the  axilla  to  midway  between  the 
apices  of  the  bony  condyles  of  the  humerus.     (Fig.  131.) 

Muscular  Guide. — At   its  upper  third  it  lies  at   the  inner 
border  of  the  coraco-brachialis;  in  the  middle  third,  at  the 


Pig.  131. 


inner  border  of  the  biceps;  in  the  lower  third,  the  inner 
border  of  the  biceps  tendon.  It  may  be  ligatured  in  three 
situations:   at  its  upper,  middle,  and  lower  thirds. 

Contiguous   Anatomy. 

Plan  of  the  Relations  of  the  Brachial  Artery. 

In  f7-ont. 
Integument  and  fasciae. 
Bicipital  fascia,  median  basilic  vein. 
Median  nerve. 
Outer  side. 
Median  nerve. 
Coraco-brachialis. 


Biceps. 


Inner  side. 
Internal  cutaneous 
and  ulnar  nerve. 
Median  nerve. 


J  Brachial  I 
j  Artery.  J 

Behind. 
Triceps. 

Musculo-spiral  nerve. 
Superior  profunda  artery^ 
Coraco-brachialis. 
Brachialis  amicus. 

Operation :  Upper  Third. — Adduct  the  arm,  and  rotate  it 
outward;  make  an  incision  about  three  inches  in  length 
along  the  inner  border  of  the  coraco-brachialis.  The  ar- 
tery being  very  superficial  is  quickly  reached.  The  median 
nerve  is  drawn  to  the  outer,  and  the  ulnar  nerve  and  ba- 


LIGATION  OF  BRACHIAL. 


I2g 


silic  vein  to  the  inner  side;  separate  it  from  the  vein,  and 
pass  the  needle  from  within  outward. 

Operation  in  the  Middle  Third 
(Fig.  132). — Place  the  arm  as  before; 
make  an  incision  three  inches  in 
length  along  the  inner  side  of  the 
biceps  muscle.  The  median  nerve 
is  found  lying  upon  and  a  little  to 
its  outer  side ;  push  it  aside,  iso- 
late the  artery  from  the  venae  comi- 
tes,  and  pass  the  needle  in  the  same 
direction  as  before. 

Operation  in  the  Lower  Third 
(Fig.  133). — Abduct  the  arm  and 
supinate  the  forearm.  Compress 
the  arm  above  to  distend  the  medi- 
an basilic  vein;  make  an  incision 
about  three  inches  in  length  along 
the  inner  border  of  the  tendon  of 
the  biceps;  draw  aside  the  median 
basilic  vein,  when  the  artery  will 
be  felt  pulsating  beneath  the  bicip- 
ital fascia;  a  suitable  sized  opening   is  now  cut  through 


Fig.  132. 


Fig.  133. 

this  fascia;  the  fore-arm  partially  flexed;  the  vessel  sepa- 
rated from  its  veins,  and  the  needle  passed  from  within  out- 
wards. 

Fallacies. — The  arteries  of  the  fore-arm  may  be  given  off 
from  the  axillary,  or  the  brachial  may  bifurcate  high  up, 
thereby  increasing  the  large  vessels  in  the  arm.  This  is  to 
be  told  by  the  comparative  size  of  the  brachial,  and  the  in- 


I30 


OPERATIVE   SURGERY. 


fluence  of  pressure  on  the  circulation  beyond  the  point 
of  proposed  ligature.  The  brachial  may  run  along  with 
the  ulnar  nerve  behind  the  inner  condyle.  If  it  be  not  in 
its  normal  site,  deep  pressure  may  detect  its  pulsations  else- 
where; which,  together  with  its   effect  on  the  circulation 

beyond,  will  determine  the  size 
and  site  of  the  vessel.  The  in- 
cisions in  the  upper  two  thirds 
may  be  made  too  far  inward, 
leading  the  surgeon  to  mistake 
the  ulnar  for  the  median  nerve. 
If  the  forearm  be  flexed  and  trac- 
tion be  made  upon  either,  its 
course  will  be  determined  and 
the  mistake  corrected. 

The  median  nerve  may  pass 
behind  the  artery  instead  of  in 
front;  when,  if  the  circulation 
from  above  be  obstructed,  the 
artery  may  escape  notice. 

Anomalous  muscular  slips  and 
unusual  muscular  development 
may  obscure  the  artery  in  its 
normal  course.  In  such  instances 
the  pulsation  will  determine  its 
location. 

Occasionally,  especially  in  fe- 
male subjects,  when  the  extrem- 
ity is  markedly  concave  on  its 
outer  surface,  due  to  an  unusual 
length  of  the  internal  condA'le, 
the  primary  incision  may  be 
made  to  the  outer  side  of  tke 
vessel.  If,  however,  it  be  made 
midway  between  the  tips  of  the 
bony  condyles,  irrespective  of 
the  overhanging  soft  parts,  this 
error  will  not  arise. 

Results. — It  has  been  ligatured 
seventy-six  times  for  hemorrhage,  with  fifty-five  recoveries. 
Ligature  of  the  Radial  Artery. — This  artery  arises  from 
the  brachial,  is  an  apparent  continuation  of  it,  and  is 
superficial  in  its  entire  course.  It  may  be  ligatured  in  any 
portion  of  its  course:    it  is,    however,  usually  ligatured  in 


Fig.  134. 


LIGATION   OF   RADIAL.  I3I 

three  situations:    at  the    upper   and  lower  thirds,  and   at 
th«  wrist. 

The  linear  guide  (Fig.  134)  to  this  vessel  is  drawn  from 
»idway  between  the  tips  of  the  bony  condyles  of  the  hum- 
erus to  the  inner  side  of  the  extremity  of  the  styloid  pro- 
cess of  the  radius.  The  muscular  guide  is  the  inner  border 
of  the  belly  of  the  supinator  longus  muscle. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  Radial  Artery. 
In  front. 

Integument — superficial  and  deep  fasciae. 
Supinator  longus. 
Inner  side.  Outer  side. 

Pronator  radii  teres,  j    Radial    )  Supinator  longus. 

Flexor  carpi  radialis.  j  Forearm  \  Radial  nerv^e  (middle  third). 

Behind. 
Tendon  of  Biceps. 
Supinator  brevis. 
Pronator  radii  teres. 
Flexor  sublimis  digitorum. 
Flexor  longis  pollicis. 
Pronator  quadratus. 
Radius. 

Operation:  Upper  Third (Y\^.  135). — Supinate  the  forearm; 
press  upon  the  arm  above  to  distend  the  superficial  veins; 
make  an  incision  about  three  inches  in  length  along  the  lin- 
ear guide  to  the  vessel.  After  going  through  the  fascia,  the 
inner  edge  of  the  supinator  longus  will  be  found  extending 
beyond,  m'erlapping  the  line;  separate  and  pull  this  outward, 
when  the  artery  will  be  seen  lying  between  its  veins,  with  the 
nerve  to  the  outer  side;  separate  the  artery,  and  pass  the 
needle  from  without  inward. 

Operation  in  the  Lower  Third  {F\g.  136). — In  this  situation 
the  vessel  is  very  superficial;  its  well-known  pulsation 
being  the  best  guide  to  it;  with  the  arm  placed  as  in  the 
preceding  position,  make  an  incision  two  inches  in  length 
along  the  course  of  the  vessel.  After  the  division  of  the 
integument  and  fascia,  the  artery  will  be  seen  surrounded 
by  loose  areolar  tissue,  accompanied  by  its  veins,  and  lying 
to  the  inner  side  of  the  tendon  of  the  supinator  longus. 
Separate  and  ligature  it,  passing  the  needle  from  the  nerve. 

Operation  at  Apex  of  Styloid  Process. — In  this  situation  the 
vessel  is  found  in  a  triangular-shaped  space  bounded  ante- 


132 


OPERATIVE  SURGERY. 


riorly  by  the  tendon  of  the  extensor  primi  internodii  pollicis; 
externally  by  that  of  the  second!  internodii  pollicis,  and  the 
base  corresponding  to  the  apex  of  the  styloid  process  of 
the  radius.  If  the  thumb  be  forcibly  extended  the  outlines 
of  the  space  will  be  well  marked. 

Operation. — Place  the  hand   midway  between  the  supina- 
tion and  pronation,  and  having  ascertained  the  exact  situ- 


FlG.  136. 


ation  of  the  tendon  of  the  extensor  primi  internodii  pollicis, 
make  an  incision  along  its  outer  border  about  an  inch  in 
length;  use  care  not  to  divide  the  superficial  veins.  The  are- 
olar tissue  and  the  extensor  primi  internodii  pollicis  are 
pushed  aside  and  the  vessel  found  somewhat  deeply  situa- 
ted.    The  needle  can  be  carried  in  either  direction.     (Fig. 

I37-) 


LIGATION   OF   ULNAR.  1 33 

Fallacies. — The  radial  artery  may  be  upon  the  fascia  and 
supinator  longus  instead  of  beneath  them;  it  may  pass  over 
the  extensor  tendons  of  the  thumb  instead  of  beneath  them. 

Results. — During  the  late  war  it  was  tied  twenty  times; 
four  died. 

Ligature  of  the  Ulnar  Artery. — This  vessel  is  larger  than 
the  radial.  It  is  given  off  from  the  brachial  about  one 
inch  below  the  bend  of  the  elbow,  passes  obliquely  inward 
and  downward  deeply  beneath  the  superficial  flexors  of  the 


Fig.  137. 

forearm,  and  gains  the  ulnar  side  a  little  above  its  middle; 
becoming  superficial,  passes  along  the  outer  side  of  the 
flexor  carpi  ulnaris  to  the  radial  side  of  the  pisiform  bone, 
where  it  terminates  in  the  superficial  palmar  arch.  It  may 
be  ligated  in  three  situations. 

The  li7iear  guide  is  drawn  from  the  extremity  of  the  inter- 
nal condyle  to  the  pisiform  bone.     (See  Fig.  135.) 

The  muscular  guide  is  the  outer  border  of  the  flexor 
carpi  ulnaris. 

Contiguous  Anatomy. 

Plan  of  Relations  of  the  Ulnar  Artery  in  the  Forearm. 
In  front. 

Superficial  layer  of  flexor  muscles.  |  TjoDer  half 
Median  nerve.  )     '^^ 

Superficial  and  deep  fasciae. 
Inner  side.  Outer  side. 

Flexor  carpi  ulnaris.  j    Ulnar    )     Flexor  sublimis  digitorum. 

Ulnar  nerve  (lower  two  thirds).    \  porlZm" ) 

Behind. 
Brachialis  amicus. 
Flexor  profundis  digitorum. 


134 


OPERATIVE   SURGERY. 


Operation:  Junction  Middle  and  Upper  Third  (Fig.  138). — 
Supinate  the  forearm  and  make  an  incision  about  three 
inches  in  length,  beginning  about  four  finger-breadths  below 


Fig.  138.      , 

the  internal  condyle,  on  the  linear  guide  to  the  vessel.  Di- 
vide the  fascia  on  a  director;  seek  for  the  line  of  connection 
between    the   borders  of   the  flexor  carpi  ulnaris  and  the 


Fig,  I40- 


flexor  sublimis  digitorum.  It  is  of  a  yellowish-white  color. 
Divide  it  on  a  director,  and  pull  the  muscles  apart,  when 
the  ulnar  nerve  will  be  seen,  to  the  outer  side  of  which  will 


LIGATION   OF   PALMAR   ARCH. 


135 


be  found  the  arter}''  with  its  accompanying  veins;  separate 
the  artery  and  pass  the  needle  from  within  outward. 

Operation  in  the  Lower  Third  (Fig.  139). — Place  the  arm 
as  in  the  preceding  operation;  extend  the  hand  to  make 
the  tendon  of  the  flexor  carpi  ulnaris  tense;  make  an  incis- 
ion about  three  inches  !n  length  along  the  radial  border 
of  this  muscle  down  to  the  fascia,  which  should  be 
divided  on  a  director,  exposing  the  tendon  of  the  flexor 
carpi  ulnaris,  which  should  be  drawn  inward,  and  the  ar- 
tery is  seen  beneath  it.  Isolate  the  vessel  from  its  veins  and 
pass  the  needle  from  within  outward. 

Operation  at  the  Wrist  (Fig.  140). — Place  the  hand  on  its 
dorsal  surface  and  make  a  curved  incision  about  two  inches 
in  length  along  the  radial  side  of  the  pisiform  bone,  with  its 
convexity  outward;  carry  it  down- 
ward along  the  side  of  that  bone 
through  the  fascia  and  fatty  tissue 
to  the  vessel.  Flex  the  hand  and 
pass  the  ligature  from  within  out- 
ward. 

Fallacies. — In  the  upper  third 
the  interspace  between  the  flexor 
carpi  ulnaris  and  flexor  sublimis 
may  be  mistaken  for  the  one  be- 
tween the  flexor  carpi  radialis 
and  the  palmarislongus  or  flexor 
sublimus  digitorum.  If  the  hand 
and  fingers  be  moved  alternately, 
the  proper  muscles  can  be  ascer- 
tained. 

The  artery  may  run  beneath  the  fascia,  or  otherwise  vary 
in  its  course;  if  not  in  its  normal  situation,  deep  pressure 
may  define  it. 

Results. — The  ulnar  artery  was  ligatured  during  the  war 
ten  times,  with  three  deaths. 

The  Superficial  Palmar  Arch  can  be  tied  at  the  seat  of  in- 
jury. It  must  be  remembered,  however,  that  beneath  it 
lie  the  tendons  of  the  flexors  of  the  fingers  and  the  divisions 
of  the  median  and  ulnar  nerves. 

Linear  Guide  (Fig.  141). — Extend  the  thumb  at  a  right 
angle  to  the  carpus,  and  draw  a  line  transversely  across 
it  corresponding  to  its  palmar  border;  this  will  denote 
the  lower  limit  of  the  arch. 

Ligature    of  the    Cofumon    Carotid. — The    right   common 


Fig.  141. 


136 


OPERATIVE  SURGERY. 


carotid  comes  from  the  innominate  artery,  and  the  left 
from  the  arch  of  aorta.  The  left  is  consequently  longer 
and  more  deeply  situated  in  the  chest.  The  left  after 
leaving  the  aorta  passes  obliquely  upward  to  a  point  oppo- 
site the  left  sterno-clavicular  articulation  ;  and,  from  this 
point  upward  the  right  and  left  common  carotids  main- 
tain substantially  the  same  course  to  the  upper  border 
of  the  thyroid  cartilage,  where  each  divides  into  the  internal 
and  external  carotids. 


Fig.  142. 


Each  vessel  may  be  ligatured  in  three  situations:  (i)  At 
the  root  of  the  neck;  (2)  below  the  omo-hyoid  muscle;  (3) 
above  that  muscle.  The  last  two  are  the  situations  com- 
monly selected,  the  first  not  being  employed  except  under 
forced  circumstances.     (Fig.  142.) 

The  linear  guide  to  the  vessel  is  a  line  drawn  from  the 
sterno-clavicular  articulation  to  midway  between  the  angle 
of  jaw,  and  mastoid  process.     (See  Fig.  125.) 

The  muscular  guide  to  the  operation  is  the  anterior  border 
of  the  sterno-cleido  mastoid. 


LIGATION   OF   COMRIOM   CAROTID. 


137 


Contigzwus  Anatomy. 

Plan  of  the  Relations  of  the  Common  Carotid  Artery. 
In  fro7it. 


Integument  and  fascia. 

Platysma. 

Sterno-mastoid. 

Sterno-hyoid. 

Sterno-thyroid. 


Externally. 
Internal  jugular  vein. 
Pneumogastric  nerve. 


j  Common  I 
I  Carotid.  ) 


Longus  colli. 


Behind. 


Omo-hyoid 

Descendens  noni  nerve. 
Sterno-mastoid  artery. 
Superior  thyroid,  lingual,  and  fa- 
cial veins. 
Anterior  jugular  vein. 

Internally. 
Trachea. 
Thyroid  gland. 
Recurrent  laryngeal  nerve. 
Inferior  thyroid  artery. 
Larynx. 
Pharynx. 


Rectus  capitis  anticus  major.  Infe; 

Recurrent  laryngeal  nerve 

Operation  below  the  Omo-hyoid.     (Fig.  143.) 


Sympathetic  nerve. 
Inferior  thyroid  artery. 


Fig.  143. 

Place  the  patient  on  the  back,  with  the  shoulders  slightly 
elevated,  and  the  head  tiarned  to  the  opposite  side;  make 
an  incision  three  inches  in  length,  beginning  a  little  above 


138  OPERATIVE   SURGERY. 

the  cricoid  cartilage,  on  the  line  stated,  and  carry  it  down- 
ward along  the  anterior  border  of  the  sterno-mastoid; 
divide  the  superficial  fascia,  platysma,  and  deep  fascia  on  a 
director,  thus  exposing  the  anterior  border  of  the  sterno- 
mastoid.  If  the  sterno-mastoid  artery  be  divided,  ligature 
it.  If  otherwise,  push  it  aside,  together  with  the  thyroid 
veins;  draw  the  sterno-mastoid  outward,  and  the  sterno- 
thyroid and  hyoid  inward,  when  the  lower  border  of  the 
omo-hyoid  will  be  seen  above;  divide  the  fascia  beneath 
these  muscles  and  draw  it  apart,  when  the  descendens 
noni  nerve  will  be  seen  resting  upon  the  inner  portion  of 
the  common  sheath  of  the  carotid,  internal  jugular  vein, 
and  the  pneumogastric  nerve:  the  artery  being  to  the  inner 
side,  the  nerve  behind  and  between  the  two  and  out  of 
sight.  Place  the  finger  upon  the  sheath,  to  ascertain  the 
exact  location  of  the  artery;  raise  a  portion  of  the  sheath 
at  its  inner  side  corresponding  to  the  site  of  the  artery 
with  a  tenaculum  or  the  thumb  forceps,  cut  a  small  open- 
ing into  it,  and  pass  the  needle  from  without  inward,  cau- 
tiously insinuating  it  between  the  vessel  and  its  sheath. 
This  manipulation  should  be  carefully  done,  else  the  vein, 
pneumogastric,  and  recurrent  laryngeal  nerves  may  be  im- 
plicated. 

Operation  above  the  Omo-hyoid. — The  vessel  is  more  super- 
ficial in  this  situation;  which  is  sometimes  denominated 
"the  site  of  election."     (See  Fig.  125^.) 

Place  the  patient  as  before,  and  make  an  incision  along 
the  anterior  border  of  the  sterno-mastoid,  beginning  at 
about  the  angle  of  the  lower  jaw,  and  extending  it  a  little 
below  the  cricoid  cartilage;  divide  the  superficial  fascia, 
platysma,  and  deep  fascia  on  a  director,  carefully  avoiding 
the  small  veins;  expose  the  anterior  border  of  the  sterno- 
mastoid  and  slightly  flex  the  head  to  relax  the  tissues  of 
the  neck;  draw  the  edges  of  the  wound  apart,  and  the 
artery  will  be  felt  pulsating  in  its  sheath.  If  the  jugular 
vein  overlap  it,  it  should  be  emptied  by  pressure  above  and 
below,  and  be  pressed  outward;  then  carefully  open  the 
sheath  as  before,  avoiding  the  descendens  noni  nerve;  pass 
the  needle  carefully  from  without  inward.  It  is  well  to 
observe  the  upper  border  of  the  omo-hyoid  muscle  before 
opening  the  sheath,  that  the  exact  location  to  apply  the 
ligature  be  assured. 

Fallacies. — The     artery    may    bifurcate    at    the    cricoid 
artilage,  and  even  lower;  however,  this  is  extremely  rare; 


LIGATION   OF   COxMMON   CAROTID. 


139 


under  such  circumstances  both  branches  should  be  secured. 
If  the  vessel  be  pressed  upon  before  the  ligature  is  tied,  it 
will  determine  the  influence  of  the  ligaturing  upon  the 
branches  above. 

The  jugular  vein  may  be  much  dilated,  lie  over  and  re- 
ceive the  impulse  of  the  artery,  hence  be  mistaken  for  it. 
This  fallacy  may  be  detei mined  if  that  vessel  be  emptied 
of  its  blood  in  the  manner  before  described.  The  thyraid 
gland  may  be  enlarged  and  obscure  the  artery  by  disptac- 


FlG.  144. 

ing  or  overfapping  it.  Under  these  conditions  it  should  be 
pushed  aside.  It  is  reported  that  the  omo-hyoid  muscle 
has  been  mistaken  for  the  artery;  the  fact  of  its  being  mus- 
cular, taken  in  connection  with  the  direction  of  its  fibres, 
together  with  other  obvious  reasons,  should  eliminate  any 
danger  of  this  mistake.  If  branches  arise  from  the  main 
trunk,  it  may  be  mistaken  for  the  external  carotid.  The 
comparative  size  of  the  vessel  and  the  influence  of  pressure 
on  the  circulation  of  the  internal  carotid  will  effectually 
solve  the  question.     If  branches  be  given  off  from  the  com- 


I40  OPERATIVE   SURGERY. 

mon  carotid  near  the  site  of  the  proposed  ligaturing,  they 
should  be  tied  also. 

Results. — This  vessel  has  been  tied  789  times  for  various 
reasons,  of  which  323,  or  about  41  per  cent,  have  perished. 

Ligaii(?-ing  of  both  cot?imon  carotids,  either  simultaneously  or 
at  variable  intervals,  has  been  done  2>^  times.  The  shortest 
interval  between  the  operations  in  which  recovery  has 
taken  place  is  four  and  one  half  days.  Instances  where 
the  interval  varied  from  thirteen  to  thirty  days  are  re- 
ported, with  recovery  of  the  patients. 

Ligature  of  the  External  Carotid. — This  artery  arises  from 
the  common  carotid  at  or  just  above  the  upper  border  of 
the  thyroid  cartilage.  It  ascends  in  a  slightly  curved 
course,  with  the  convexity  forward,  to  a  point  midway 
between  the  neck  of  the  condyle  of  the  lower  jaw  and  the 
external  auditory  meatus.  The  upper  part  of  its  course  lies 
in  the  substance  of  the  parotid  gland  (Fig.  144). 

This  artery  may  be  tied  in  two  situations:  (i)  Between 
the  posterior  belly  of  the  digastric  and  its  origin;  (2)  above 
the  belly  of  the  digastric.  The  former  situation  is  the  one 
to  be  selected,  if  possible. 

The  linear  and  the  muscular  guides  are  substantially  the 
same  as  for  the  common  carotid. 

Contiguous  Anatomy. 

Plan  of  the  Relations  of  the  External  Carotid. 
In  front.  Behind. 

Integument,  superficial  fascia.  Superior  laryngeal  nerve. 

Platysma  and  deep  fascia.  Stylo-glossus. 

Hypoglossal  nerve.  |  External  1  Stylo-pharyngeus. 

Lingual  and  facial  veins.  '  Carotid.  )  Glosso-pharyngeal  nerve. 

Digastric  and  stylo-hyoid  muscles.  Parotid  gland. 

Parotid  gland,  with  facial  nerve  and 
temporo-maxillary  vein  in  its  sub- 
stance. 

Internally. 
Hyoid  bone. 
Pharynx. 
Parotid  gland. 
Ramus  of  jaw. 

Operation. — Below  the  digastric  muscle,  with  the  patient 
on  the  back,  head  slightly  extended  and  turned  to  the  op- 
posite side,  make  an  incision  along  the  anterior  border  of 
the  sterno-mastoid,  beginning  opposite  the  angle  of  the 
lower  jaw,  and  carry  it  downward  to  a  point  opposite  the 


LIGATION   OF   EXTERNAL   CAROTID.  I4I 

cricoid  cartilage.  Divide  the  superficial  fascia,  platysma, 
and  deep  fascia  on  a  director;  expose  the  anterior  border 
of  the  sterno-mastoid.  The  edges  of  the  wound  should  be 
well  drawn  apart,  when  the  hypoglossal  nerve  and  the 
digastric  and  stylo-hyoid  muscles  will  come  into  view. 

The  end  of  a  grooved  director  should  now  be  employed 
to  separate  and  push  aside  the  lingual  and  facial  veins,  to- 
gether with  the  areolar  tissue  and  lymphatic  glands  that 
rest  upon  the  vessel.  Expose  the  artery  and  pass  the  liga- 
ture from  without  inward.  The  internal  jugular  vein  oft- 
times  overlaps  the  vessel,  and  should  be  carefully  drawn 
aside,  or  treated  as  recommended  in  ligaturing  the  com- 
mon carotid. 

Before  the  ligature  is  tied  the  following  facts  should  be 
carefully  observed:  (i)  If  it  be  the  external  carotid  around 
which  the  ligature  is  passed,  this  can  be  told  by  pressing 
upon  the  vessel  and  observing  its  effect  upon  the  circula- 
tion of  the  facial  ;  (2)  the  distance  of  the  seat  of  the  liga- 
ture from  collateral  branches;  this  can  only  be  deter- 
mined by  carefully  exposing  the  vessel  for  half  an  inch 
above  and  below  the  seat  of  the  ligature.  If  vessels  be 
found  within  this  extent,  they  too  should  be  ligatured  to 
destroy  the  possibility  of  any  interference  with  the  forma- 
tion of  the  internal  clot;  (3)  that  the  ligature  be  not  car- 
ried around  both  the  external  and  internal  carotid  at  or 
just  above  their  point  of  bifurcation;  if  it  be  around  both, 
pressure  will  check  the  pulsation  of  both;  if  but  one  it  will 
have  a  like  effect  on  its  circulation. 

Other  Fallacies. — Enlarged  lymphatic  glands  resting  on 
the  vessel  may  be  mistaken  for  it.  They  need  cause  but 
momentary  thouglit,  since  their  circumscribed  outline  and 
mobility  will  determine  their  nature.  If  large  they  should 
be  removed,  otherwise  they  can  be  pushed  aside.  The 
superior  thyroid  branch  may  be  confounded  with  the 
lingual.  If  the  course  of  the  respective  vessels  be  observed 
they  can  be  readily  told  apart;  the  superior  thyroid  arises 
nearest  the  bifurcation,  arches  upward  and  forward,  then 
passes  quite  directly  downward.  The  lingual  does  not 
arch  downward,  but  passes  upward  and  inward  to  gain  the 
upper  border  of  the  greater  cornu  of  the  hyoid  bone,  which 
can  be  easily  outlined  by  the  finger. 

Operation  aboi'e  the  Digastric. — Make  an  incision  from  the 
lobe  of  the  ear  to  the  greater  cornu  of  the  hyoid  bone, 
along  the  anterior  border  of  the  sterno-mastoid.     Divide 


142  OPERATIVE   SURGERY. 

the  superimposed  tissues  as  before  down  to  the  digastric 
muscle;  pull  it,  along  with  the  stylo-hyoid,  downward,  and 
the  jugular  vein  outward,  if  it  be  in  the  way,  and  pass  the 
ligature  from  without  inward. 

Results. — The  external  carotid  has  been  ligatured  seventy- 
one  times,  with  three  deaths. 

Ligature  of  the  Superior  Thyroid  Artery. — This  vessel 
comes  from  the  external,  or  from  the  common  carotid  near 
the  point  of  its  bifurcation.  It  passes  upward  and  for- 
ward at  first  quite  superficially,  then  runs  downward  and 
less  superficially  to  enter  the  thyroid  gland. 

Operation. — Make  an  incision  about  three  inches  in  length 
along  the  anterior  border  of  the  sterno-mastoid,  its  centre 
corresponding  to  a  point  opposite  the  thyro-h3^oid  space. 
The  carotid  sheath  should  be  exposed  as  in  the  ligaturing 
of  that  vessel,  and  the  artery  sought  for  along  its  inner  bor- 
der. 

Ligature  of  the  Lingual  Artery. — This  vessel  arises  from 
the  external  carotid  opposite  the  h5^oid  bone,  and  runs  up- 
ward and  inward  to  about  one  quarter  of  an  inch  above 
the  upper  border  of  its  greater  cornu,  and  passes  horizon- 
tally parallel  with  it,  resting  upon  the  middle  constrictor  of 
the  pharynx,  and  being  directly  covered  first  by  the  digas- 
tric and  stylo-hyoid  muscles,  and  more  internally  by  the 
hyo-glossus.  It  then  ascends  between  the  hyo-glossus  and 
genio-hyo-glossus  muscles  and  terminates  in  the  ranine 
artery. 

It  has  no  superficial  muscular  guide;  a  linear  guide  may 
be  drawn  parallel  with,  and  a  fourth  of  an  inch  above  the 
greater  cornu  of  the  hyoid  bone;  practically,  however, 
the  upper  border  of  the  greater  cornu  of  the  hyoid  bone 
marks  its  situation.  It  may  be  ligated  in  three  situations: 
(i)  At  apex  of  greater  cornu;  (2)  between  that  cornu  and 
the  posterior  bell}^  of  the  digastric;  (3)  in  the  triangle  made 
by  the  digastric,  mylo-hyoid,  and  hypo-glossal  nerve. 

Operation  between  the  digastric  and  the  greater  cor?iu.  Place 
the  patient  on  the  back,  and  turn  the  head  to  the  oppo- 
site side;  carefully  define  the  greater  cornu  of  the  hyoid 
bone.  If  the  neck  be  fleshy,  this  will  be  somewhat  difficult. 
It  can  be  made  more  prominent  on  the  side  of  the  opera- 
tion by  pushing  against  its  body  on  the  opposite  side, 
being  careful  to  press  it  directly  towards  that  point,  other- 
wise it  may  mislead  the  operator.  After  the  patient  is 
thoroughly  anaesthetized  to  prevent  spasmodic  movements 


LIGATION   OF   LINGUAL. 


143 


of  the  hyoid  bone,  make  an  incision  about  two  or  three 
inches  in  length  parallel  with  the  upper  border  of  the  cor- 
nu,  which  should  pass  downward  and  outward  to  nearly 
the  anterior  border  of  the  sterno-mastoid  (see  Fig.  125^). 
Divide  the  superficial  fascia,  platysma,  and  deep  fascia  on  a 
director;  draw  upward  the  sub-maxillary  gland  and  divide 
the  deep  aponeurosis,  and  the  digastric  and  stylo-hyoid 
muscles,  and  the  hypoglossal  nerve  will  be  exposed.  Ac- 
curately locate  the  greater  cornu  with  the  finger,  draw  up 
the  digastric  and  the  stylo-hyoid  muscles,  and  hypo-glossal 
nerve  with  a  blunt  hook,  push  aside  the  lingual  vein  if  seen, 
and  pick  up  the  fibres  of  the  hyo-glossus  with  a  pair  of 
forceps,  and  incise  them  in  the  direction  of  the  external 


..-SSSSJ 


Fig.  145. 


incision  about  one  quarter  of  an  inch  above  the  greater 
cornu  ;  beneath  them  will  be  found  the  vessel,  sometimes 
accompanied  by  the  lingual  vein  (Fig.  145).  Pass  the 
needle  from  the  vein.  Before  tj'ing  the  ligature,  ascertain 
if  pressure  will  stop  its  pulsation. 

Ligature  in  the  Third  Situation. — This  is  often  called  the 
place  of  election.  Make  an  incision  transversely  two  inches 
long,  concavity  upward,  and  its  centre  just  within  the  mid- 
dle of  the  cornu  of  the  hyoid  bone.     Divide  the  integument, 


144  OPERATIVE   SURGERY. 

superficial  fascia  and  platysma,  carefully  avoiding  the  super- 
ficial veins;  divide  the  deep  fascia  and  pull  upward  the 
sub-maxillary  gland,  when  the  posterior  belly  of  the  digas- 
tric will  come  into  view;  also  the  posterior  border  of  the 
mylo-hyoid  and  the  hypoglossal  nerve,  accompanied  usu- 
ally by  the  lingual  vein.  Carefully  outline  the  triangle 
before  mentioned,  pinch  up  the  fibres  of  the  hyo-glossus, 
and  divide  them  midway  between  the  h3^oid  bone  and  the 
nerve,  when  the  artery  will  be  seen  beneath.  Separate  it 
from  the  vein,  if  it  has  not  been  seen  before,  and  deposit 
the  ligature  (Fig.  147), 


Fig.  146. 
a.  Hyoid  Bone.     I.   Hyo-glossus  Muscle,    c.  Sub-maxillary  Gland,     d.  Digastric 

Muscle.  (T.  Stylo-hyoid.  f.  Mylo-hyoid.  g.  Lingual  Artery  passing  Beneath  the  Hyo- 
glossus  Muscle.  Its  course  beneath  it  is  indicated  by  dotted  lines.  The  hypoglossal 
nerve  and  lingual  vein  are  seen  above  the  artery,  the  nerve  passing  upon  and  the  vein 
beneath  the  muscle  (the  latter  is  unusual),    h.  Hypoglossal  Nerve. 

Ligatwe  of  the  First  Portion. — In  this  situation  the  vessel 
is  tied  between  the  point  of  its  giving  off  and  the  tip  of  the 
greater  cornu  of  the  hyoid  bone. 

Operation. — Make  an  incision  three  inches  in  length  run- 
ning obliquely  downward  and  backward,  its  centre  corre- 
sponding to  the  greater  cornu.  The  various  tissues  are 
carefully  divided  as  before,  the  ninth  pair  of  nerves  exposed. 
The  numerous  veins  located  in  the  course  are  now  pushed 
aside  and  the  artery  carefully  sought  for  at  the  point  of  the 
cornu,  and  ligatured.  This  operation,  on  account  of  the 
absence  of  a  definite  deep  guide  to  the  location  of  the  vessel 


LIGATION   OF   FACIAL.  1 45 

and  the  uncertainty  of  its  point  of  origin,  together  with  the 
great  number  of  large  veins  in  the  course  of  the  search,  is 
much  less  feasible  than  either  of  the  other  two. 

Fallacies. — The  hypo-glossal  nerve  may  be  mistaken  for 
the  arter)^  The  nerve  rests  on  the  hyo-glossus;  the  artery 
runs  beneath  it.  This,  together  with  the  pulsation  of  the 
arter}'  and  other  distinctive  anatomical  features,  should  ren- 
der the  discrimination  easy.  It  is  well  to  know,  however, 
tliat  the  movements  of  the  tissues  dependent  on  the  acts 
of  respiration  ftiake  it  somewhat  difficult  and  often  im- 
possible to  detect  the  arterial  impulse.  If,  however,  the 
supposed  artery  be  carefully  isolated,  ligature  passed 
around  it,  and  a  good  light  thrown  into  the  wound,  its 
tortuous  outline  Avill  be  noticed  with  each  pulsation.  The 
pulsation  can  be  seen  the  best  in  the  interval  of  the  respira- 
tory acts,  when  the  tissues  are  quiet. 

The  lingual  vein  may  be  mistaken  for  the  artery.  This 
vessel  sometimes  runs  with  the  artery  behind  the  hyo- 
glossus;  more  frequently,  however,  it  rests  on  this  muscle. 
It  has  the  characteristic  color  of  a  vein,  and  is  larger  than 
the  artery.  After  the  division  of  the  fibres  of  the  hyo- 
glossus,  the  search  for  the  vessel  must  be  conducted  cau- 
tiously to  avoid  opening  into  the  pharynx. 

Results. — It  has  been  tied  repeatedly  for  the  purpose  of 
controlling  haemorrhage  from  the  tongue,  and  delaying  a 
morbid  growth  of  the  same,  and  with  great  advantage. 

Ligature  of  the  Facial  Artery. — The  facial  is  one  of  the 
large  branches  of  the  external  carotid.  It  arises  from  it 
just  above  the  tip  of  the  greater  cornu,  or  about  one  inch 
from  the  bifurcation  of  the  common  carotid,  passes  forward 
and  upward  beneath  the  ramus  of  the  lower  jaw,  going 
through  the  substance  of  the  sub-maxillary  gland,  and 
gains  the  external  surface  of  the  ramus  at  the  anterior  in- 
ferior angle  of  the  masseter  muscle,  lying  in  a  groove  in 
tiie  outer  border  of  the  bone.  The  masseter  muscle,  there- 
fore, becomes  its  muscular  guide  in  a  portion  of  its  course. 
It  may'be  ligatured  in  two  situations:  in  the  neck,  and  as 
it  crosses  the  ramus  of  the  jaw;  this  being  the  better. 
In  the  former,  the  head  is  turned  to  the  opposite  side 
and  an  incision  of  about  three  inches  in  length  is  made 
obliquely  downward  and  forward  a  little  in  front  of  the 
anterior  border  of  the  sterno-mastoid,  its  centre  being  at  a 
point  about  one  fourth  of  an  inch  above  the  tip  of  the 
greater  cornu.     The  dissection  is  carefully  made  as  in  the 


146 


OPERATIVE   SURGERY. 


preceding  instance,  pushing  aside  the  facial  and  other  con- 
tiguous veins,  drawing  up  the  digastric  and  passing  the 
ligature. 

Operation  on  the  Ramus  of  the  Jaw. — Place  the  patient  as 
before,  draw  the  skin  upward  over  the  ramus,  so  when  re- 
traction occurs  the  scar  will  be  beneath  the  jaw;  make 
an  incision  about  two  inches  in  length  along  the  border  of 
the  jaw,  divide  the  tissues  on  a  director  (Fig.  125),  down 
to  the  vessel;  isolate  it  and  pass  the  ligature.  If  a  re- 
sulting scar  be  of  no  moment,  the  primary  incision  can  be 
made  in  the  long  axis  of  the  vessel  along  the  anterior 
border  of  i^he  ♦"asseter  muscle.     (Fig.  i47«) 


Fig.  147. 

Fallacies. — At  its  origin  this  vessel  may  be  mistaken  for 
the  lingual.  Interruption  of  the  circulation  will  easily  de- 
termine the  difference. 

Ligature  of  the  Tefuporal  Artery. — The  temporal  is  one  of 
the  terminal  branches  of  the  external  carotid.  It  begins  in 
the  substance  of  the  parotid  gland  between  the  neck  of  the 
lower  jaw  and  the  external  meatus  and  passes  upward 
across  the  root  of  the  zygoma,  subcutaneously  where  its 
pulsation  can  be  distinctly  felt;  about  two  inches  above 
the  zygoma  it  divides  into  its  terminal  branches. 

The  Zygoffia  is  the  guide  to  it. 

Operation  (see  Figs.  125  and  147). — Make  an  incision 
in  the  line  of  the  vessel,  as  indicated  by  its  pulsation, 
about  one  fourth  of  an  inch  in  front  of  the  tragus,  and 


LIGATION   OF   OCCIPITAL. 


147 


one  inch  in  length;  divide  the  skin  and  fascia;  expose  the 
vessel  and  pass  the  needle  so  as  to  avoid  the  vein  and 
nerve. 

The  Ligature  of  the  Occipital  Artery. — This  artery  arises 
from  the  external  carotid  a  trifle  above  the  facial,  passes 
upward  and  outward  between  the  transverse  process  of  the 
atlas  and  the  mastoid  process  of  the  occipital  bone.  It  then 
passes  over  the  posterior  portion  of  the  skull  midway  be- 
tween the  external  occipital  protuberance  and  the  mastoid 
process.  (Fig.  126.)  It  has  no  muscular  guide.  It  may  be 
tied  at  its  origin  or  behind  the  mastoid  process. 


Fig.  148. 

Operatio7i  at  its  origin. — Make  an  incision  along  the  inner 
border  of  the  sterno-mastoid,  about  three  inches  in  length, 
its  centre  corresponding  to  a  point  a  little  above  the  apex 
of  the  greater  cornu  of  the  hyoid  bone.  Divide  the  super- 
ficial tissues  carefully  on  a  director;  separate  the  areolar 
tissue  with  the  blunt  end  of  a  director;  push  aside  the 
veins  and  find  the  posterior  belly  of  the  digastric.  A  little 
below  this  will  be  seen  the  ninth  pair  of  nerves,  winding 
around  the  object  of  search.  Pass  the  needle  from  the 
nerve. 

Operation  Behind  the  Mastoid  Process  {¥'1^.  148). — Make  an 
incision   about  two   inches  in  length  one  half  inch  behind 


148  OPERATIVE  SURGERY. 

and  a  little  below  the  mastoid  process.  Divide  the  in- 
tegument, and  attachments  of  the  sterno-mastoid  and  the 
splenius  muscles,  feel  the  pulsation  at  the  bottom  of  the 
wound.    Isolate  the  artery  and  pass  the  ligature. 

Ligaturing  of  Veins. 

Veins,  like  arteries,  maybe  ligatured  in  their  continuity  or 
at  their  divided  extremities.  Large  venous  trunks,  when  di- 
vided in  the  course  of  an  operation,  should  always  be  tied, 
otherwise  they  ma)''  give  rise  to  an  objectionable  amount 
of  oozing,  which  will  interfere  with  the  rapidity  of  the 
union  of  the  divided  surfaces,  and  possibly  require  the 
re-opening  of  the  wound  to  secure  the  bleeding  points.  If  a 
large  vein  be  nicked  during  an  operation — as  the  internal 
jugular — during  the  removal  of  growths  from  the  neck, 
ligatures  may  be  thrown  around  it,  above  and  below  the 
nick,  rather  than  to  tie  the  nicked  portion.  The  latter  pro- 
cedure is  liable  to  be  followed  by  secondary  hemorrhage. 
The  practice  of  ligating  the  nick,  or  of  sewing  its  divided 
borders  by  fine  catgut,  is  strongly  extolled  by  many  writers. 
If  it  be  determined  to  tie  the  vessel,  it  should  be  done  above 
and  below  the  cut,  else  the  return  circulation  will  cause 
secondar)'  hemorrhage.  If  it  be  possible  to  surround  the 
patient  with  the  degree  of  surveillance  necessary  to  detect 
and  treat  secondary  hemorrhage  at  the  onset,  I  am  of  the 
opinion  that  the  practice  of  sewing  the  cut  with  the  con- 
tinuous or  other  suitable  form  of  suture  offers  the  better 
opportunity  for  rapid  recovery.  Aside  from  the  ligaturing 
of  veins  on  account  of  traumatism,  they  are  ligated  in  their 
continuity  for  the  purpose  of  causing  their  occlusion  in  those 
cases  where  they  are  in  a  dilated  or  varicose  condition. 

Operations  for  Varicose  Veins. 

When  the  veins  of  the  lower  extremities  become  too 
much  distended  to  be  amenable  to  palliative  measures,  it  is 
often  necessary  to  resort  to  operative  interference,  which 
has  for  its  object  the  occlusion  of  the  distended  canals. 
Injection,  acupressure,  and  ligation  are  the  common  means 
employed. 

Injection. — The  vein  is  compressed  above  and  below  the 
proposed  point  of  injection  by  the  fingers,  leaving  an  in- 
tervening space  of  an  inch  or  less,  or  by  small  pads  con- 


LIGATION   OF   VEINS.  149 

fined  in  position  with  adhesive  piaster;  the  latter  being  the 
better.  The  isolated  portion  is  then  slowly  injected  with 
twenty  or  thirty  drops  of  a  twenty  per  cent  solution  of 
liqi  or-ferri  subsulphatis  and  water.  Almost  immediately 
the  contents  of  the  vessel  will  become  coagulated,  when 
the  pressure  can  be  remtved.  The  limb  should  be  kept 
quiet  for  a  few  days;  and  any  tendency  to  undue  inflam- 
mation combated.  The  results  of  this  operation,  while  not 
so  favorable  as  other  expedients,  are,  nevertheless,  very 
satisfactory.  Of  the  103  cases,  some  time  since  reported, 
79  were  cured,  one  perished,  and,  of  the  remainder,  16  were 
failures 

Acupressure. — There  is  substantially  no  difference  between 
this  method  and  the  application  of  the  same  means  for  ar- 
resting the  circulation  of  arterial  trunks.  (See  Fig.  43.)  It 
consists  simply  of  carrying  a  thoroughly  purified  needle  or 
pin,  which  may  or,  may  not  have  been  constructed  for  the 
purpose,  beneatli  the  vein  at  various  situations,  and  com- 
pressing the  intervening  tissues  by  means  of  a  carbolized 
thread  of  silk  or  cotton  yarn.  The  pins  are  removed  on  the 
sixth  or  seventh  day,  depending  on  the  degree  of  ulceration 
produced.  Caution  should  be  observed  that  the  pins  be 
not  passed  through  instead  of  beneath  the  vein,  otherwise 
a  serious  phlebitis  may  follow, 

Subcutajieous  Ligation. — This  is  accomplished  by  passing  a 
carbolized  needle,  armed  with  a  fine  wire  or  catgut  liga- 
ture, in  front  of  and  across  the  vein;  after  which  the  direc- 
tion is  changed  so  as  to  carry  it  beneath  the  vessel  and  out 
at  the  point  of  entrance.  The  wire  is  then  twisted  and  cut 
short,  and  the  opening  closed  antiseptically.  If  catgut  be 
employed,  it  is  to  be  tied  and  cut  in  the  same  manner. 
Three  or  four  of  these  constrictions  may  be  applied  at  in- 
tervals of  an  inch.  If  the  blood  in  the  intervening  spaces 
becomes  necrosed,  giving  rise  to  fluctuation,  it  should  be 
evacuated;  since  absorption  is  then  impossible. 

A  varicose  condition  of  the  hemorrhoidal  veins  causes  a 
disease  denominated  hemorrhoids,  or  piles;  for  the  cure  of 
which  various  radical  measures  are  recommended.  The 
patient  is  prepared  by  a  saline  cathartic,  followed  by  an  in- 
jection, a  few  hours  prior  to  the  operation.  He  should  then 
be  etherized,  placed  upon  a  table  of  suitable  height,  with 
the  buttocks  drawn  down  to  the  edge;  the  thighs  are  then 
elevated,  drawn  apart,  and  the  nates  separated.  If  the 
growths  be  of  the  external  variety,  and  not  inflamed,  they 


I50 


OPERATIVE   SURGERY. 


can  be  nipped  off  with  a  pair  of  scissors;  being  careful  not 
to  cut  them  too  closely,  else  the  resulting  cicatrization  may 
cause  a  narrowing  of  the  anal  orifice.  Local  anaesthesia  is 
sufficiently  potent  to  meet  the  indications  of  the  operation. 
If  the  hemorrhoid  be  distended,  tender,  and  painful,  it  may 
be  necessary  to  employ  general  anaesthesia.  The  tumor 
should  then  be  taken  between  the  thumb  and  finger,  raised 
up,  drawn  out,  transfixed  near  the  base,  and  cut  outward; 
the  pressure  will  then  evacuate  its  contents,  after  which  a 
pellet  of  fine  oakum  saturated  with  balsam  of  Peru  should 
be  placed  in  the  bottom  of  the  sack,  and  the  operation  is 
completed.  When  the  transfixing  incision  is  made,  it 
should  be  done  in  the  direction  of  the  radiating  folds  of 
the  anus,  to  facilitate  union. 

Operations  for  internal  hemorrhoids  are  quite  numerous,  but 
the  following  are  believed  to  secure  the  best  results: 

Excision. — This  method  is  reckoned  among  those  which 


jt_ ^^^— -^^ 


Fig.  149. 


secure  the  best  results  in  selected  cases.  It  causes  little 
after  pain,  and  recovery  takes  place  within  a  week  or  ten 
days.  It  is  applicable  to  those  cases  wher»  but  three  or 
four  tumors  exist,  which  are  not  very  large,  and  have  well 
defined  bases.  The  sphincter  should  be  well  dilated  and 
the  anus  opened  with  a  speculum  or  retractor.  The  pile  is 
then  seized  at  the  base  with  a  vulsellum,  and  cut  off  with  a 
pair  of  scissors  above  the  point  grasped,  Avhich  should  be 
held  till  all  arterial  hemorrhage  is  stopped  by  twisting  the 
bleeding  points.  After  it  has  ceased  a  pledget  of  lint  satu- 
rated with  tannin  and  water,  or  with  liquor  ferri  subsulpha- 


INTERNAL   HiEMORRHOIDS.  I51 

tis,  is  applied  to  the  cut  surfaces,  and  the  patient  kept  quiet 
for  t\Yenty-four  to  forty-eight  hours. 

This  operation  has  been  frequently  performed,  and  with 
eminent  success. 

Crushing. — This  method  consists  in  crushing  the  pedicle 
of  the  growth  in  the  instrument  especially  constructed  for 
that  purpose  (Fig.  149).  It  is  not  suitable  for  universal 
application,  but  rather  to  those  tumors  which  possess  well- 
defined  bases.  If  the  integument  be  connected  with  the 
tumor  it  should  be  incised,  otherwise  too  great  pain  is 
caused.  The  patient  being  prepared  as  in  the  preceding 
instance,  the  pile  is  pulled  between  the  bars  of  the  instru- 
ment by  the  aid  of  a  hook  or  a  vulsellum,  after  which  the 
screw  is  turned  tightly  against  it.  The  projecting  portion 
is  then  cut  off.  The  instrument  is  retained  in  position  for 
half  a  minute  or  so,  to  insure  against  the  danger  of  hemor- 
rhage. While  this  method  may  be  classed  among  the  satis- 
factory ones,  it  possesses  no  superiority  over  the  treatment 
by  ligature;  and  as  a  rule  causes  more  pain,  less  speedy  re- 
covery, and  exposes  the  patient  to  the  probable  danger  of 
subsequent  hemorrhage. 

Ligation. — This  method  may  be  employed  with  or  without 
incision.  The  latter  being  far  preferable.  The  treatment 
without  incision  is  to  pass  a  needle,  armed  with  a  double 
ligature  of  stout  carbolized  silk,  through  the  base  of  the 
growth,  tying  each  half  separately;  after  which  the  pile  is 
cut  off  below  the  ligature.  If  strong  catgut  be  used,  the 
ends  should  be  divided  close  to  the  pedicle;  while  with  silk 
one  end  may  be  allowed  to  hang  from  the  anus. 

Ligature  with  incision  consists  in  drawing  down  the  tumors 
by  aid  of  forceps  or  volsellum  to  the  anus,  or  beyond  it,  and 
with  a  pair  of  curved  scissors  dividing  them  from  their  con- 
nection with  the  sub-mucous  membrane  from  below  up- 
ward, parallel  with  the  bowel,  far  enough  to  leave  the  pile 
connected  only  by  a  slim  pedicle,  around  which  a  strong 
ligature  should  be  cast  and  securely  tied.  The  ligature 
portion  is  thus  cut  off  and  the  parts  returned.  The  vessels 
connected  with  the  growth  enter  it  from  above  downward, 
parallel  with  the  gut,  and  are  therefore  secure  from  injury, 
if  ordinary  caution  be  taken.  The  injection  of  carbolic  acid 
and  astringent  agents,  together  with  the  application  of 
caustics,  is  hardly  entitled  to  the  dignity  of  being  consid- 
ered an  operation.  Nor  are  the  results,  notwithstanding 
the  claims  of  some  to  the  contrary,  on  the  whole  better  than 


152 


OPERATIVE   SURGERY, 


by  ligature,  either  with  or  without  incision.  The  occa- 
sional severe  inflammatory  reaction,  often  followed  by 
abscesses  and  gangrene,  detract  from  that  which  might 
otherwise  become  an  extremely  satisfactory  remedy.  The 
full  explanation  of  these  methods  can  be  found  in  syste- 
matic treatises  upon  the  subject. 

Varicocele. — This  is  caused  by  a  varicose  condition  of  the 
spermatic  veins  (Fig.  150).  The  treatment  of  the  varicose 
veins  of  the  cord,  like  that  in  other 
situations,  is  divided  into  the  pallia- 
tive and  radical  methods;  the  object 
of  the  latter  being  to  obliterate  the 
lumen  of  the  vessels.  The  same 
dangers  appertain  to  operations  upon 
these  veins,  as  upon  those  of  other 
portions  of  the  venous  system.  Ery- 
sipelas, phlebitis,  pyaemia,  to  which 
may  be  added  a  consequent  atrophy 
of  the  testicle  depending  upon  the  oc- 
clusion of  the  vein  and  artery,  may 
follow ;  therefore  radical  measures 
directed  to  the  vessels  should  not  be 
entertained  until  the  disease  becomes 
a  source  of  great  discomfort  and  even 
distress.  The  palliative  treatment 
consists  in  shortening  the  cord  by 
raising  the  scrotum  and  its  contents, 
which  lessens  the  weight  of  the  col- 
umn of  blood  contained  in  the  ves- 
sels, This  is  achieved  by  the  various 
forms  of  suspensories,  as  Morgan's 
(Fig.  151),  and  the  one  in  ordinary 
use.  Should  these  serve  to  relieve 
the  urgent  symptoms,  the  patient 
may  not  deem  it  desirable  to  submit 
to  an  operation  of  any  kind.  If,  how- 
ever, the  characteristic  symptoms 
recur  or  continue,  then  the  palliative  operation  for  shorten- 
ing the  scrotum  should  be  done. 

Excision  of  the  Scrotum. — The  instruments  required  for  this 
simple  operation  are  the  scrotal  clamp — the  one  devised 
by  Dr.  Henry  being  in  every  way  suitable  (Fig.  152) — a 
sharp  bistoury,  needles  armed  with  silver  wire,  or  carbolized 
silk,  artery  forceps,  and  catgut    ligatures.      The  scrotum 


EXCISION   OF   SCROTUM. 


153 


should  be  thoroughly  cleansed  and  the  patient  anaesthetized; 
the  clamp  is  then  applied  to  the  side  afflicted  by  drawing 
the  bottom  of  the  scrotum  between  the  blades,  which 
should  be  applied  as  nearly  as  possible  parallel  with  the 
raphe;  all  danger  of  including  the  testicle  is  obviated  by 
pressing  it  upward  to  the  ex- 
ternal abdominal  ring.  When 
a  sufficient  amount  of  tissue 
is  grasped  to  meet  the  indica- 
tion, the  blades  are  tightened 
to  cut  off  all  circulation,  at 
the  same  time  securely  hold- 
ing the  scrotal  tissues;  the  pro- 
truding portion  is  then  trans- 
fixed, on  a  level  with  the  ad- 
justable bar  (Fig.  152-2),  by 
a  sharp  and  narrow-bladed 
scalpel,  and  cut  off.  Before  the 
blades  are  loosened  it  is  bet- 
ter to  pass  the  sutures,  which 
should  be  at  least  ten  inches  in  length,  through  the  divided 
borders.  Having  adjusted  them,  remove  the  clamp,  tie 
the  bleeding  points,  and  close  the  wound.  Caution  must 
be  taken  always  to  stop  all  bleeding  points  before  the  edges 
of  the  wound  are  united;  else,  owing  to  the  looseness  of 


Fig.  151. 


Fig.  152. 


the  scrotal  tissues,  an  ordinary  oozing  may  cause  the  forma- 
tion of  large  bloody  clots,  which  must  be  removed.  If  a 
drainage  tube  be  introduced  throughout  its  course  and 
allowed  to  protrude  at  its  most  dependent  extremity,  this 
danger  will  be  avoided.     Place  the  patient  in  bed,  elevate 


154 


OPERATIVE   SURGERY. 


the  scrotum,  and  dress  the  wound  antiseptically.  It  usually 
heals  quickly,  and  affords  sufficient  relief  to  amply  recom- 
pense the  patient  for  the  annoyance  incurred.  If  the  in- 
strument just  described  be  not  at  hand,  the  operation 
should  not  be  delayed  for  this  reason.  A  clamp  of  great 
practical  utility  may  be  extemporized  from  long-bladed 
forceps,  or  by  adjusting  to  the  scrotum  two  narrow  bars  of 
metal  or  stiff  wood,  the  extremities  of  which  can  be  firmly 
held  by  the  hands  of  an  assistant. 

Radical  Treatment  for  Varicocele. — The  means  employed 
to  obliterate  the  dilated  vessels  are  quite  numerous.  They 
all,  however,  accomplish  the  result  by  compression.  Only 
such  as  are  considered  practically  consistent  with  the  safety 
of  the  patient  are  here  described.     In  all  the  operations 


Fig.  153. 


Fig.  154. 


great  care  must  be  exercised  to  avoid  the  vas  deferens  and 
artery.  They  lie  posteriorly  to  the  enlarged  and  worm-like 
congeries  of  vessels,  around  which  the  compression  is  to  be 
applied.  If  the  patient  be  caused  to  lie  down  with  the  hips 
elevated,  the  blood  will  return  from  the  varicose  veins  into 
the  general  circulation,  after  which  the  vas  deferens  and 
artery  can  be  easily  isolated  and  pulled  aside.  If  the 
patient  then  assume  an  erect  position  the  veins  will  again 
become  distended,  when,  if  pressure  be  maintained  upon 
the  cord  at  the  external  ring,  the  vessels  can  be  distinctly 
outlined  if  the  patient  be  placed  in  the  recumbent  position. 
The  operator  having  thus  carefully  located  the  vas  deferens, 
the  patient  can  be  etherized  and  the  operation  be  pro- 
ceeded with. 


RADICAL  CURE   OF  VARICOCELE.  155 

Compressio?i  by  Pins  (Fig.  153). — This  consists  simply  of 
passing  a  strong  pin  in  front  of  the  vas  deferens  and  artery, 
and  throwing  around  its  protruding  extremities  an  elastic 
ligature,  or  cotton  yarn,  drawn  sufficiently  tight  to  cut  off 
the  circulation.  This  should  be  duplicated  at  about  one 
inch  from  the  first  application.  The  pins  can  be  withdrawn 
at  the  end  of  three  or  four  days. 

Compression  by  Wires  (Videl's). — This  is  done  by  passing 
a  stout  wire  either  in  front  of  or  behind  the  veins,  prefer- 


FiG.  155, 

ably  the  latter,  then  passing  a  second  but  thinner  one  at 
the  opposite  side,  but  through  the  same  opening  in  the  in- 
tegument (Fig.  154).  They  are  then  twisted  together  till 
the  veins  are  thoroughly  compressed  and  rolled  around 
them  (Figs.  155  and  156). 

Subcutaneous  Ligation. — This  is  accomplished  by  carry- 
ing a  needle  armed  with  silver  wire  between  the 
veins  and  cord,  returning  it  at  the  point  of  entrance, 
going  in  front  of  the  veins.  The  wire  is  then  twisted 
firmly.  A  strong  silk  ligature  can 
be  applied  in  similar  manner. 
However,  the  amount  of  tissue  in 
their  grasp  renders  the  separation 
somewhat  tedious.  The  process 
of  separation  can  be  hastened  by 
tying  the  ligature  over  a  small 
cylinder  of  elastic  tubing,  the  re- 
sistancy  of  which  will  exercise  a 
constant  traction  (Fig.  157).  If 
this  be  done,  a  button  should  be 
introduced  between  the  tissues  and  tubing  to  protect  the 
skin. 

A  strong  catgut  ligature  can  be  carried  around  the  dilated 
veins  and  caused  to  emerge  at  the  point  of  entrance  by 
means  of  a  curved  needle,  tied,  ends  cut  short,  and  permit- 
ted to  remain  until  it  is  absorbed,  which  will  take  place  in 
five  or  six  days.  This  is.  in  my  opinion,  the  safest  and 
simplest  method  and  equally  efficacious. 

T/ie  Double-Loop  Compression  of  Ricord  (Fig.  158). — This 
is   an  excellent  plan,  and  can  be  readily  done  by  passing 


156 


OPERATIVE   SURGERY. 


a  needle  armed  with  a  silk  ligature  between  the  veins  and 
the   vas  deferens ;    to  this  is  fastened  a  double  ligature, 


Fig.  IS7. 


which  is  drawn  through  and  left  in  position.  The  needle 
with  its  silk  ligature  is  then  passed  in  front  of  the  veins  in 
the  opposite  direction,  entering 
and  emerging  at  the  points  pre- 
viously made.  A  second  double 
ligature  is  then  drawn  through  and 
left  in  position.  The  extremities 
on  the  respective  sides  are  now 
Fig.  158.  tucked  through  the  loops    on   the 

same  side  and  drawn  tight,  and  tied  over  a  narrow  roller 
or  piece  of  elastic  tubing.  The  ligatures  will  cut  a  way 
through  in  five  or  six  days.  The  methods  of  exposure, 
division,  and  exsection  of  the  vessels  are  more  dangerous, 
and  not  infrequently  result  in  death  from  pyaemia. 

Venesection. — While  the  withdrawing  of  blood  from  a  vein 
can  hardly  be  classed  as  an  operation  of  much  moment  in 
a  surgical  sense,  yet  the  infrequency  of  its  employment  at 
the  present  time  is  quite  apt  to  render  the  details  connected 
therewith  somewhat  uncertain  in  the  minds  of  a  majority 
of  the  practitioners  of  the  present  generation.  The  veins 
selected  for  the  procedure  are  the  internal  saphenous  at  the 
ankle,  median  basilic,  median  cephalic,  and  external  jugu- 
lar. The  instruments  required  are  the  ordinary  thumb  lan- 
cet, or  a  curved  or  sharp-pointed  bistoury,  the  first,  however. 


VENESECTION. 


157 


possessing  the  greater  number  of  traditional  virtues.  If 
these  be  not  at  hand,  either  of  the  others  can  be  used  as 
satisfactory  substitutes.  If  the  region  of  the  elbow  be  se- 
lected, the  median  cephalic  is  preferred  on  account  of  its 
greater  distance  from  the  brachial  artery.  The  arm  should 
be  constricted  by  a  bandage  drawn  sufficiently  tight  to  ob- 
struct venous  return,  without  interfering  with  arterial  circu- 
lation: this  will  cause  the  veins  to  become  prominently  dis- 
tended, unless  the  patient  be  very  fleshy.  The  veins  should 
be  well  defined  by  the  finger,  and  held  in  position  by  the 
thumb  or  finger  placed  just  below  the  point  for  incision, 
which  is  made  obliquely  to  the  transverse  diameter,  and  of 
sufficient  depth  to  freely  open  the  vessel,  without  severing 
it  (Fig.  159).     The  flow  may  be  increased  by  causing  the 


Fig.  159. 

patient  to  firmly  grasp  a  stick  or  broom-handle;  it  may  be 
impeded  by  the  interposition  of  the  subcutaneous  fat, 
which  should  be  pushed  aside.  The  amount  drawn  will  be 
governed  by  the  strength  of  the  patient,  as  well  as  his 
position.  If  standing  or  sitting  its  effects  will  be  sooner 
felt  than  if  in  a  recumbent  posture.  Usually,  however, 
from  half  a  pint  to  a  pint  will  suffice.  The  flow  is  stopped 
by  removing  the  bandage  above  and  applying  the  finger  to 
the  bleeding  point;  after  which  a  small  compress  is  placed 


158 


OPERATIVE  SURGERY. 


over  the  incision,    and   confined   in  position    by  adhesive 
plaster,  so  arranged  as  not  to  impede  the  venous  return. 

These  directions  will  apply  with  equal  force  to  venesection 
in  all  situations  other  than  of  the  external  jugular.    If  this 
vein    be    selected,  the  compress  is  placed   just   above   the. 
clavicle,  and  confined  in  position  by  a  bandage  carried  un- 
der the  opposite  axilla.     The  finger  is  then  placed  above 


Fig.  i6o. 


the  point  of  proposed  incision,  and  the  vessel  opened  at 
right  angle  with  the  fibres  of  platysma  myoides  muscle. 
The  finger  must  always  be  placed  on  the  opening  before 
the  compress  is  removed,  in  order  to  prevent  the  entrance 
of  air  into  the  circulation. 

Transfusioji. — This  is  a  means    sometimes  employed   to 


TRANSFUSION. 


159 


overcome  the  exhaustion  produced  by  disease,  or  loss  of 
blood;  the  latter  being  the  only  condition  to  which  it  can, 
thus  far,  be  said  to  be  practically  adapted.  It  consists  in 
conveying  the  blood  from  one  person  to  another,  either 
directly,  or  by  collecting  it  in  a  suitable  receptacle,  remov- 
ing the  fibrin,  and  introducing  the  resulting  blood  plasma 
and  corpuscles.  The  dangers  to  be  avoided,  are,  the  intro- 
duction of  air,  blood  clots,  and  too  great  a  quantity  of 
blood,  which  might  overpower  an  already  weakened  heart. 
From  six  to  eight  ounces  are  usually  sufficient,  and  it  should 
be  thrown  slowly  and  carefully,  watcliing  its  effects  upon 
the  circulation,  respiration,  and  sensorium  of  the  patient. 
If  its  introduction  causes  a  depression  of  the  pulse,  or  gives 
rise  to  nervous  tremors,  or  difficulty  in  breathing,  it  should 
cease   at   once.     The  blood,  to  be  transfused,   should   be 


Fig.  161. 

taken  from  a  person  of  strong  physique,  and  free  from  any 
constitutional  taint. 

Direct  Transfusion  from  arm  to  arm.  The  requirements 
for  tliis  are,  an  apparatus  for  the  transmission  of  the 
blood,  together  with  a  pair  of  forceps  and  a  scalpel  to 
open  the  vessels.  A  basin  of  water  or  saline  solution  at 
a  temperature  of  about  100°  F.,  into  which  the  instrument 
should  be  laid  to  impart  to  it  the  requisite  degree  of 
warmth,  and  to  exclude  the  air.  The  arm  of  the  donor 
and  receiver  are  constricted  above  the  point  for  incision,  as 
in  phlebotomy;  the  skin  covering  the  distended  vessels  is 
pinched  up,  transfixed,  and  cut  out,  leaving  the  veins  ex- 
posed at  bottom  of  the  wounds;  they  are  then  seized  with 
a  pair  of  forceps,  and  a  V-shaped  opening  made  with  the 
scissors  (Fig.  160).  The  tube  A  (Fig.  161)  is  then  taken 
from  the  bottom  of  the  basin,  and  with  the  thumb  applied 


i6o 


OPERATIVE  SURGERY. 


to  its  larger  extremity  to  keep  it  filled,  is  inserted  into  the 
opening  in  the  vein  of  the  receiver;  the  tube  B  is  inserted 
in  like  manner  into  the  vein  of  the  donor  (Fig.  i6i),  after 
which  the  propelling  power  of  the  apparatus,  likewise  filled 
with  fluid  and  kept  so  by  turning  the  stop-cocks,  is  attached 
to  the  two  tubes;  the  cocks  are  now  opened,  and  the  fluid 
contained  in  the  instrument  is  thrown  into  the  circulation 
by  squeezing  the  bulb  C,  while  the  tube  D  is  compressed 
(Fig.  i6i).  After  the  bulb  C  is  emptied,  and  before  it  is 
permitted  to  expand,  the  compression  should  be  changed 
from  d  to  d' .  If  the  bulb  be  now  allowed  to  expand  it 
will  become  filled  with  the  blood  of  the  donor,  which  can 
be  pushed  into  the  circulation  as  in  the  preceding  instance. 
The 'bulb  should  be  allowed  to  fill  slowly,  and  the  amount 


introduced  is  estimated  by  counting  the  number  of  times 
it  is  emptied.  After  the  operation  is  completed,  the  in- 
cisions are  treated  the  same  as  in  phlebotomy.  The  instru- 
ment devised  by  Fryer  (Fig.  162)  differs  from  the  former  in 
being  cast  whole,  with  an  additional  bulb,  which  does 
away  with  the  metallic  couplings,  and  presents  a  continu- 
ously smooth  surface  to  the  blood  current;  and,  moreover, 
the  additional  bulb  saves  time  by  producing  an  almost  con- 
tinuous current.  It  will  be  seen  that  a  funnel  is  added  to 
this  instrument  which  allows  it  to  be  employed  in  mediate 
transfusion. 

Mediate  transfusion  is  collecting  the  blood   from  the  arm 


TRANSFUSION. 


i6i 


Fig.  163. 


Fig.  164. 


l62  OPERATIVE   SURGERY. 

of  the  donor  and  injecting  it  into  the  circulation,  either 
with  or  without  the  removal  of  the  fibrin.  For  this  pur- 
pose the  instrument  devised  by  Collins  (Fig.  163)  can  be 
especially  recommended.  It  consists  of  a  pump  attached 
to  a  funnel,  in  such  a  manner  as  to  carry  the  blood  easily, 
and  without  danger  of  coagulation,  or  the  introduction  of  air. 
It  can  be  used  equally  well  with  the  defibrinated  and  with  the 
unwhipped  blood:  in  the  latter  it  is  particularly  convenient, 
since  the  blood  can  be  caught  in  the  funnel  and  injected 
while  flowing  from  the  donor;  this  saves  time,  and  avoids 
the  blood  changes  induced  by  its  exposure.  In  the  use  of 
this,  and  all  other  implements  brought  in  contact  with  the 
blood,  the  temperature  of  the  instrument,  and  of  the  blood 
injected,  should  be  kept  at  about  100°  F.  by  means  of  water, 
or  a  saline  solution.* 

If  defibrinated  blood  be  employed,  it  should  be  prepared 
by  agitation,  after  being  collected  in  a  vessel  of  the 
temperature  stated  (Fig.  164),  then  strained  (Fig.  165)  into 
the  funnel  of  the  instrument  and  pumped  into  the  system. 

The  introduction  into  the  funnel,  or  into  the  bulbs,  of 
two  or  three  ounces  of  the  saline  solution;  or  of  a  carbonate 
of  ammonia  solution,  four  to  six  grains  to  the  ounce,  pre- 
vents the  entrance  of  air  to  the  instrument,  and  also  has  a 
stimulating  effect  upon  the  patient. 

Intra-venous  injection  of  milk  has  been  done  to  counteract 
the  conditions  similar  to  those  calling  for  the  use  of  blood. 
The  milk  should  be  freshly  drawn  from  the  cow  and  covered 
with  fine  gauze;  the  carbolized  being  the  better,  through 
which  it  is  strained  into  a  transfusion  instrument,  which 
can  be  extemporized  by  joining  to  one  end  of  a  rubber 
tube  a  glass  funnel,  and  to  the  other  a  small  conducting 
canula. 

If  the  canula  be  introduced  into  the  vein,  and  the  funnel 
be  raised  after  having  been  filled  with  six  or  eight  ounces 
of  milk,  the  force  of  gravity  will  become  the  propelling 
agent. 

Arterial  transfusion  has  been  advocated  on  the  basis  that 


*  I^  Chloride  of  Sodium 3  i- 

Chloride  of  Potassium. gr.  vi. 

Phosphate  of  Soda gr.  iii. 

Carbonate  of  Soda 3  i- 

Aqua I  XX. 

TtL — Heat  to  100  F. 


TRANSFUSION. 


163 


it  conveys  the  blood  more  equably  to  the  heart,  with  less 
danger  of  exciting  undue  disturbance  of  the  circulation. 
The  admission  of  a  small  amount  of  air  does  no  harm,  and 
the  danger  of  phlebitis  is  avoided.  The  vessels  selected 
are  the  radial,  or  the  posterior  tibial  at  the  ankle,  which 
is  exposed,  and  three  ligatures  are  placed  around  it;  the 
proximal  one  is  tied,  ana  the  distal  tightened  sufficiently  to 
cut  off  collateral  circulation.     The  vessel  is  then  opened, 


Fig.  165. 


the  tube  inserted,  and  tied  in  position  by  the  middle  or  third 
ligature;  the  distal  one  is  then  relaxed  and  the  blood  forced 
into  the  circulation.  As  soon  as  this  is  completed  the  dis- 
tal ligature  is  tied,  and  the  intervening  portion  of  the  vessel 
removed  with  the  tube.  The  vein  may  be  tied  in  venous 
transfusion  by  placing  two  ligatures.  Tie  the  distal  one, 
open  the  vein,  introduce  the  tube,  then  tie  the  proximal  one; 
this  will  prevent  all  loss  of  blood. 

Capillaries, — This  system  of  vessels,  like  the  venous,  may 


1 64  OPERATIVE   SURGERY. 

undergo  dilatation  of  sufficient  size  to  create  distinct  but 
slowly  developing  and  painless  deformities,  or  tumors. 
The  morbid  process  may  be,  and  usually  is,  limited  entirely 
to  the  capillaries  of  the  integument;  however,  the  larger 
vessels  are  not  infrequently  involved,  in  the  beginning,  or 
during  their  development;  they  likewise  vary  in  size,  shape, 
and  color.  The  simplest  form  is  known  as  the  "mother's 
mark,"  ''  birth-mark,"  etc. 

A  iDirth-mark  can  be  treated  by  pressure,  caustic,  hot 
needles,  vaccination,  etc.,  depending  upon  its  size  and  situa- 
tion. It  is  not  well  to  interfere  with  them  at  all  except  by 
simple  means,  unless  they  increase  rapidly  in  size.  The 
majorit)^  of  these  growths  will  disappear  of  themselves  be- 
fore their  presence  will  become  a  source  of  annoyance  or 
regret  to  the  possessor.  There  are,  however,  several  simple 
means  which  will  often  hasten  their  departure.  The  use  of 
simple  compresses,  repeated  application  of  collodion,  vac- 
cination, if  it  be  located  suitably  therefor.  The  method  in- 
troduced by  Squire  some  time  since,  which  bade  fair  at  one 
time  to  meet  the  desired  end,  can  be  employed. 

The  "  mark"  is  frozen  with  an  ether  spray,  and  numerous 
parallel  incisions  are  made  about  one  sixteenth  of  an  inch 
apart,  and  extending  the  same  depth,  and  the  whole  cov- 
ered with  blotting-paper,  held  upQn  it  with  sufficient  force 
to  prevent  an}'-  gaping  of  the  cuts  and  escape  of  blood; 
after  fifteen  or  twenty  minutes  the  paper  is  thoroughly  wet 
with  water  and  removed.  Sometimes  a  thin  underljnng 
clot  of  blood  will  be  found;  this  must  be  carefully  washed 
away  with  water  and  a  soft  brush.  It  is  sometimes  neces- 
sary to  repeat  the  operation,  when  the  incisions  should  be 
made  in  the  opposite  direction.  If  proper  care  be  taken,  in 
suitable  cases  a  perfect  cure  is  secured  without  any  scar- 
ring. The  injection  of  ergot,  liquor  ferri  subsulphatis,  and 
various  other  astringents,  have  been  recommended.  They 
are,  however,  uncertain  in  their  action,  and  are  liable  to  be 
followed  by  inflammation,  ulceration,  and  sometimes  by 
embolism.  The  solutions  can  be  injected  by  aid  of  the  or- 
dinary hj^podermic  S}'ringe,  three  or  four  drops  at  a  time, 
in  various  portions  of  the  growth,  or  hot  needles  can  be  in- 
troduced at  various  points.  The  application  of  red  heat 
around  the  base  and  over  the  surface  of  the  growth  by 
means  of  the  Paquelin  cautery  is  an  admirable  method,  pro- 
vided it  involves  the  skin  alone,  or  only  the  capillaries  in 
the  tissue  immediatelv  beneath  it.     It  is  usuallv  followed 


NAEVI. 


165 


In  it  the 


by  more  or  less  disfigurement,  depending  upon  the  extent 
of  the  cautery. 

If  it  be  of  large  size,  persistent,  of  a  dark  color  and 
markedly  elevated,  it  is  suitable  for  subcutaneous  ligation. 
This  is  done  in  several  ways,  depending  upon  the  size  and 
shape  of  the  tumor,  and  fancy  of  the  operator. 

(Fig.  166.)  This  represents  a  simple  method, 
needle,  armed  with  a  strong,  well-car- 
bolized  hemp  or  silk  ligature,  is  thrust 
through  the  integument  at  its  base,  and 
carried  as  far  as  possible  around  the 
base,  and  passed  out,  to  be  again  intro- 
duced at  the  point  of  exit,  and  carried 
still  further  around,  and  pushed  through 
as  before,  and  so  on  until  it  is  caused  to 
emerge  at  the  first  point  of  insertion; 
the  ends  are  then  tied  in  a  firm,  hard  knot. 

(Fig.  167.)  In  this  a  double  ligature  is  carried  through 
the  base  and  divided;  each  portion  is  then  carried  around 
its  half  of  the  base  as  before,  and  tied.  This  is  applicable 
to  those  having  a  larger  base.     Fig.  168  represents  the  ap- 


FlG.  166. 


Fig.  167. 


Fig.  iC 


plication  of  the  ligature  to  quarter-sections  of  the  base.  It 
is  employed  when  the  growth  is  large.  Pass  a  double  liga- 
ture through  the  centre  of  the  base,  cut  the  loop  near  to  its 
centre,  leaving  one  end  of  the  divided  thread  in  the  eye  of 
the  needle;  then,  after  threading  the  needle  with  the  other 
end  of  the  portion  of  the  ligature  which  was  liberated  by 
the  division  of  the  loop  (Fig.  169),  pass  the  needle  through 
the  base  at  right  angles  to  its  primary  course.  The  ends 
are  then  to  be  firmly  tied  after  the  integument  has  been  in- 
cised, to  allow  the'  ligature  to  sink  deeply  into  the  base, 
as  well  as  to  avoid  the  pain  and  ulceration  incident  to  the 
constriction  of  the  integument  (Fig.  170).  It  will  simplify 
the  selection  and  uniting  of  the  proper  extremities  if  one 
half  the  ligature  be  colored  before  its  primary  introduction. 


i66 


OPERATIVE  SURGERY. 


Fig.  171  represents  the  ligation  of  a  growth  with  an  elon- 
gated base.  In  this  the  double  ligature  is  required,  and 
should  be  colored  as  before;  pass  it  through  the  base  from 
side  to  side,  commencing  and  terminating  just  outside  of 
the  extreme  limits  of  the  growth;  if  the  white  loops  be  now 
divided  on  one  side  and  the  black  on  the  other,  independ- 


FlG.  169. 


Fig.  170. 


Fig.  171- 


ent  sets  of  ligatures  will  be  had,  which  should  be  tied;  the 
skin  coming  within  the  grasp  of  each  ligature  is  incised  an 
in  the  preceding  instance.  The  separation  of  the  growth 
is  hastened  by  the  use  of  an  elastic  or  rubber  ligature,  ap- 
plied in  a  similar  manner. 


NERVOUS    SYSTEM. 


The  brain,  spinal  cord,  and  the  nerves  arising  from  the 
cerebro-spinal  axis,  owing  to  the  various  morbid  processes 
and  injuries  to  which  they,  together  with  their  coverings, 
are  subjected,  are  often  the  seat  of  common  and  yet  im- 
portant surgical  procedures. 

Hydrocephalus. — Tapping  for  the  removal  of  the.  super- 
fluous fluid  is  the  only  practical  surgical  procedure  to 
which  this  condition  is  amenable.  This  may  be  done  with 
a  small  aspirating  trocar,  or,  what  is  better,  with  an  aspira- 
tor. In  either  instance  the  puncturing  agent  is  introduced 
through  the  anterior  fontanelle,  close  to  its  outer  border, 
and  passed  perpendicularly  into  the  fluid  accumulation. 
The  fluid  must  be  slowly  withdrawn,  accompanied  by  mod- 
erate and  equable  pressure  upon  the  external  surface. 
Whenever  any  manifestations  referable  to  the  circulatory 
or  nervous  centres  appear,  the  needle  should  be  withdrawn 


MENINGOCELE  AND   HYDRO-RACHIS.  167 

and  the  puncture  carefully  closed.  Often  the  removal  of 
less  than  three  or  four  ounces  will  cause  feebleness  of  the 
pulse,  contraction  of  the  pupil,  and  evidences  of  approach- 
ing convulsion.  After  the  withdrawal  of  the  fluid,  gentle 
and  universal  pressure  should  be  maintained  by  aid  of  band- 
ages, adhesive  plaster,  or  tightly-fitting  perforated  rubber 
cap.  Care  is  necessary,  else  the  combined  pressure  of  re- 
accumulating  fluid  and  external  dressing  will  cause  alarm- 
ing symptoms. 

Meningocele  is  a  protrusion  of  the  meninges  of  the  brain, 
caused  by  an  accumulation  of  hydrocephalic  fluid  within 
the  cranium,  and  must  of  necessity  occur  before  the  clos- 
ure of  the  fontanelles.  It  may  be  present  at  any  point  of 
separation  between  the  cranial  bones,  although  more  fre- 
quently at  the  posterior  fontanelle  than  elsewhere.  As  a 
rule,  little  can  be  done,  other  than  to  protect  the  tumor 
from  external  irritation.  If  it  have  a  well-defined  pedicle, 
it  can  be  clamped  and  the  fluid  withdrawn,  either  by  incis- 
ion, or  with  a  small  trocar.  The  clamp  must  be  applied 
with  caution,  else  the  pressure  caused  by  tightening  of  its 
blades  may  produce  convulsions  or  other  nervous  phenom- 
ena. If  it  be  determined  to  puncture  it,  a  small  amount 
of  fluid  may  be  withdrawn,  when  the  clamp  can  be  the 
more  readily  adjusted.  As  long  as  the  pedicle  is  open,  any 
operative  interference  is  liable  to  be  followed  by  death 
from  a  resulting  meningitis.  If  the  pedicle  be  occluded, 
incision  may  be  done  and  the  tumor  removed.  In  all  in- 
stances where  it  is  removed,  sufficient  integument  should 
be  left  to  insure  a  complete  and  proper  closure  of  the  di- 
vided surfaces. 

Hydro-rachis. — This  is  a  congenital  defect,  comprising  a 
cleft  in  the  laminae  of  the  vertebrae,  and  a  protrusion  of  the 
membranes  of  the  spinal  cord.  It  occurs  more  frequently 
in  the  lumbar  region,  although  it  is  found  in  the  other  por- 
tions of  the  spinal  column.  Various  operative  expedients 
have  been  employed  to  cure  the  defect,  nearly  all  of  which 
have,  at  one  time  or  another,  resulted  in  isolated  cures. 

The  two  methods  which  have  secured  the  best  results 
are:  i.  Repeated  punctures  with  a  small  needle  at  various 
intervals  through  the  sides  of  the  sack,  followed  b}^  gentle 
and  uniform  pressure  to  the  surface.  2.  Consists  of  inject- 
ing into  the  sack,  which  should  be  partially  emptied  of  its 
fluid,  one  or  two  drachms  of  the  iodo-glycerine  solution, 
which  is  made  by  dissolving  ten  grains  of  iodine  and  thirty 


i68 


OPERATIVE  SURGERY. 


grains  of  iodide  of  potassium  in  one  ounce  of  glycerine. 
Exercise  caution  that  none  of  the  fluid  escapes  after  the 
operation.  This  must  be  repeated  from  time  to  time,  al- 
ways allowing  the  irritation  due  to  the  previous  operation 
to  subside  before  it  is  again  repeated.  This  method  has 
been  very  successful.  Of  forty-four  cases  treated,  thirty- 
five  were  cured. 

Trephining  the  cratiium  is  an  operation  which  is,  without 
doubt,  performed  more  frequently  than  the  requirements 
of  the  majority  of  cases  will  warrant.  In  every  instance, 
before  attempting  it,  the  indications  should  be  most  care- 
fully studied. 

The  special  instruments  required  for  the  operation  are 
the  trephine  (Figs.  172,  173,  174),  the 
conical  being  by  far  the  safer;  an  ele- 
vator (Figs.  175,  176,  177)  and  rongeur 
(Fig.  178),  sequestrum  forceps  (Figs. 
179  and  179^),  gouges  and  mallet  (Figs. 
180,  181,  182,  183,  184).  The  traditional 
tooth-pick,  and  the  brush,  to  remove  the 
dust  from  the  track  of  the  trephine, 
while  not  absolutely  necessary,  have, 
nevertheless,  especially  the  former,  be- 
come so  closely  associated  with  the  op- 
eration as  to  be  entitled  to  a  most  re- 
spectful  consideration.     The  patient  is 


Fig.  173. 


Fig.  174. 


Fig.  172. 

prepared  by  shaving  the  head  for  a  considerable  distance 
around  the  seat  of  the  proposed  operation.  If  unconscious, 
an  anaesthetic  is  unnecessary. 

Operation. — Make  an  incision  through  the  scalp  down  to 
the  bone  of  a  size  and  shape  as  to  best  expose  the  portion  of 
bone  to  be  attacked,  and  at  the  same  time  to  avoid  large 
vessels  and  to  secure  good  drainage.  Lay  back  the  integu- 
mentary flap,  along  with  the  periosteum  covering  the  por- 
tion of  bone  to  be  removed.  Lower  the  centre-pin  a  little 
below  teeth  of  the  trephine,  and  fasten  it  firmly  in  position 
by  means  of  its  adjusting  screw;  place  the  point  of  the 
centre-pin   as  nearly  as  practicable   upon   that  portion  of 


TREPHINING- 


169 


Fig.  175. 


CA5'A'EU_.P>AZAaQ3;C0.Wf.EORa  , 

Fig.  178. 


Fig.  179. 


Fig.  179a. 


CASWELL.HAZARD.i.CO  .Vy.F.FORO. 

Fig.  180, 


I70 


OPERATIVE  SURGERY. 


Fig.  183. 


Fig.  184. 


the  solid  and  undepressed  bone  which,  when  removed, 
will  allow  the  best  opportunity  of  elevating  that  which  is 
depressed;  provided,  however,  that  it  be  not  placed  over 
the  course  of  the  middle  meningeal  artery,  or  a  large 
sinus  (Fig.  185).  The  trunk  of  the  middle  meningeal  artery 
is  located  an  inch  and  a  half  behind  the  external  angular 
process  of  the  frontal  bone,  and  the  same  distance  above 
the  zygoma.  The  median  line  of  the  skull  from  the  root 
•of  the  nose  to  the  occipital  protuberance  corresponds  to 
the  superior  longitudinal  sinus.  The  course  of  the  lateral 
sinus  is  indicated  by  a  line  drawn  from  the  occipital  pro- 
tuberance to  the  anterior  border  of  the  mastoid  process. 
Bear  firmly  upon  the  instrument,  at  the  same  time  turn  it 
quickly  from  right  to  left,  till  a  suitable  track  is  established 
to  retain  it  in  position  (Fig.  186).     The  centre-pin  is  then 


TREPHINING.  I7I 

withdrawn,  and  fastened  in  place,  otherwise  it  may  perfor- 
ate the  membranes. 

The  instrument  must  be  held  perpendicularly  to  the  point 
of  section,  and  the  pressure  evenly  distributed;  if  not,  one 
side  will  be  penetrated  more  quickly  than  the  other,  thereby 
endangering  the  laceration  of  the  membranes.  During 
the  process,  the  trephine  must  be  frequently  raised  from 
the  track,  that  it  may  be  cleared  of  bone-dust,  the  color 
of  which  should  be  carefully  noticed;  at  first  it  is  of  a  pale 
white,  but  as  soon  as  the  diploe  are  reached  it  becomes  red- 
dened; from  this  time  on  the  tooth-pick  must  be  frequently 
used  to  clear  out  the  track  as  well  as  to  detect  the  first  point 
of  complete  section.  But  little  pressure  is  now  allowable, 
since  to  use  it  might  force  the  crown  of  the  instrument 


through  the  membranes  and  the  brain  structure  itself,  es- 
pecially if  it  be  of  a  horizontal  pattern.  If  the  button  of 
bone  be  percussed  with  the  handle  of  a  scalpel  or  forceps, 
it  will  emit  a  low  pitched  sound,  and  vibrate  when  a  con- 
siderable portion  of  the  circle  is  divided;  moreover,  it  can, 
probably,  be  raised  from  its  bed  at  this  time  by  the  aid  of 
the  elevator.  As  soon  as  the  button  is  removed,  the  ele- 
vator is  inserted  beneath  the  depressed  portion,  and  it  is 
raised  to  its  pfpper  level. 

This  is  sometimes  difficult  to  accomplish,  owing  to  the 
dovetailing  of  the  fragments.  The  solid  bone  is  used  as  a 
fulcrum,  when  much  force  is  necessary.  If  great  force  be 
used,  and  a  fragment  be  suddenly  loosened,  its  sharp  or 


172 


OPERATIVE   SURGERY. 


jagged  border  may  cut  through  the  membranes;  it  is  there- 
fore necessary  that  force  be  used  in  a  guarded  manner. 

All  loose  fragments  are  to  be  removed;  those  that  will 
retain  their  position  when  replaced,  owing  to  continuity  of 
structure,  may  be  allowed  to  remain.  All  projecting  points 
of  bone  must  be  cut  away,  else  the  pulsation  of  the  brain 


Fig.  i86. 


may  cause  them  to  perforate  the  dura-mater.  Clots  of  blood 
and  pus  are  likewise  to  be  cleared  out.  If  the  compress- 
ing agents  be  below  the  dura-mater  it  may  be  opened 
sufficiently  to  admit  of  their  escape;  before  it  is  done, 
however,  their  presence  should  be  clearly  established.  If 
the  dura-mater  be  lacerated,  it  may  be  closed  by  fine  cat- 
gut sutures,  especially  when  the  opening  is  large  enough 


OPERATIONS   UPON  NERVES.  1 73 

to  endanger  the  formation  of  hernia  cerebri.  If  the  me- 
ningeal branches  be  divided  or  a  sinus  opened,  the  hemor- 
rhage is  controlled  by  antiseptic  compresses,  so  applied  as 
not  to  exert  undue  pressure  on  the  brain.  If  the  mem- 
branes be  lacerated,  the  fragments  of  bone  removed  must 
be  fitted  to  each  other  in  order  that  the  absence  of  any- 
osseous  portion  may  be  ascertained  and  sought  after. 

The  wound  should  now  be  thoroughly  cleansed  with  car- 
bolic acid,  the  flaps  adjusted,  suitable  drainage  established, 
and  the  antiseptic  dressing  applied.  It  is  often  possible  to 
elevate  the  fragments  without  the  use  of  the  trephine,  an 
expedient  that  should  always  be  tried,  if  any  reasonable 
prospect  of  success  be  apparent. 

Nerves  of  the  Cerebro- Spinal  Axis. — Owing  to  neuralgia, 
spasm,  tremor,  etc.,  it  may  be  become  necessary,  after  all 
ordinar)'-  means  have  failed,  to  operate  upon  the  trunk  of 
the  nerve  involved,  either  by  division,  excision,  or  stretch- 
ing. The  first  method  can  afford  but  temporary  relief, 
since  the  divided  extremities  will  speedily  unite. 

If  excision  be  done,  not  less  than  two  inches,  if  possible, 
should  be  removed  from  the  continuity  of  the  trunk,  other- 
wise at  a  greater  or  lesser  period  the  extremities  will  be- 
come united.  If  the  nerve  be  a  small  one,  the  tendency  to 
union  is  less;  but  the  rule  to  remove  a  long  piece  must  not 
be  deviated  from.  Stretchitig  consists  in  cutting  down  on 
the  affected  nerve,  seizing  it  with  the  fingers,  and  making 
firm  and  steady  traction  for  a  minute  or  two.  This  is  ap- 
plied more  properly  to  the  large  nerves,  and  those  which 
cannot  be  divided  without  the  sacrifice  of  important  func- 
tions. 

Supra- Orbital  Nerve. — This  may  be  divided  or  excised  at 
its  exit  from  the  supra-orbital  foramen  or  notch.  Locate 
the  notch  by  the  fingers  of  the  left  hand,  then  pass  the  point 
of  a  narrow  bistoury  beneath  the  integument,  from  its  inner 
to  its  outer  side;  turn  the  edge  backward,  and  cut  firmly 
down  and  across  the  opening  upon  its  inferior  wall. 

Resection. — This  can  be  done  by  elevating  the  brow,  and 
making  an  incision  between  it  and  the  lid,  one  inch  in 
length,  down  upon  the  site  of  the  nerve;  its  branches  are 
then  sought  for,  and  exsected  or  stretched,  as  seems  better. 
The  nerve  may  be  pulled  out  with  a  small  blunt  hook  from 
the  roof  of  the  orbit,  and  excised  before  it  enters  the  for- 
amen; or,  it  may  be  stretched  and  allowed  to  remain. 

The  infra-orbital  nerves  are  the  terminal  branches  of  the 


174  OPERATIVE  SURGERY. 

supra-maxlllary  division  of  the  fifth  pair:  they  escape  from 
the  infra-orbital  foramen. 

The  infra-orbital  foramen  is  about  four  lines  below  the 
lower  edge  of  the  orbit,  and  nearly  on  a  line  extending 
from  the  bicuspid  teeth  to  the  supra-orbital  foramen.  The 
nerve  may  be  divided  through  the  mouth  by  first  recog- 
nizing the  location  of  the  foramen,  and  placing  the  finger 
upon  it;  then  make  a  narrow  incision,  beginning  at  the  fold 
of  the  cheek  and  maxilla,  carrying  it  upward  in  the  line 
before  indicated,  till  within  a  short  distance  of  the  for- 
amen, when  with  a  sharp-pointed  pair  of  scissors  the  nerves 
are  divided  as  they  emerge.  They  may  also  be  divided 
through  an  external  incision  made  directly  down  upon  the 
foramen. 

The  Superior  Maxillary  Nerve. — This  may  be  excised, 
divided,  or  stretched  in  its  course  along  the  floor  of  the 
orbit,  or  at  its  exit  from  the  foramen  rotundum.  It  maybe 
attacked  on  the  floor  by  passing  a  tenatome  about  two 
thirds  of  an  inch  backward  in  the  line  of  its  course,  turn- 
ing the  edge  downward,  and  cutting  upon  and  through 
the  thin  floors  of  the  orbit.  Its  terminations  at  the  infra- 
orbital foramen,  are  then  exposed,  and  the  several  portions 
pulled  out.  Through  a  narrow  incision  of  the  soft  parts  in 
this  situation  a  blunt  hook  can  be  introduced,  the  nerve 
caught  up  and  stretched.  The  whole  of  the  nerve  can  be 
removed  from  the  canal,  and  sometimes  further  posterior- 
ily  if  an  incision  be  made  about  an  inch  and  a  half  in 
length  along  the  lower  border  of  the  orbit;  the  tissues 
raised  and  the  nerve  isolated  from  the  artery,  raised  on  a 
hook  and  divided;  or  by  pulling  out  the  central  portion, 
either  by  a  ligature  previously  applied,  or  with  a  pair  of 
forceps.  If  the  more  formidable  operation  of  its  division, 
as  it  escapes  from  the  foramen  rotundum,  be  attempted, 
the  initiatory  incision  through  the  soft  parts  should  be  of  a 
shape  and  extent  to  best  expose  the  site  of  the  proposed 
operation;  the  V,  -|-,  U,  -\  shaped  ones  are  selected, 
according  to  the  fancy  of  the  operator.  In  either  instance, 
its  central  portion  should  correspond  as  nearly  as  possible 
to  the  infra-orbital  foramen.  After  the  flap  is  raised  the 
crown  of  a  small  trephine  or  drill  is  applied  to  the  bone  so 
as  to  open  into  the  antrum  along  the  course  of  the  nerve, 
which  is  carefully  followed  backward  to  the  spheno-maxil- 
lary  fossa  by  cutting  away  the  floor  of  the  canal  with  a  small 
sharp  chisel.     It  is  then  carefully  isolated  from  the  tissues 


OPERATIONS  UPON  NERVES.  175 

in  the  fossa  back  to  the  foramen  of  exit,  and  divided  with 
a  pair  of  curved  scissors;  the  internal  maxillary  artery  runs 
through  the  fossa,  and  should  be  carefully  avoided.  If  it 
be  cut,  it  should  be  ligated  if  possible;  not  infrequently  firm 
pressure  will  check  the  hemorrhage. 

The  Inferior  Dejital  Nerve. — This  nerve  may  be  divided, 
excised,  or  stretched  before  it  enters  the  jaw;  in  its  course 
through  it,  and  at  its  exit  from  the  mental  foramen.  In 
the  first  situation,  an  incision  is  made  about  an  inch  and  a 
half  in  length  along  the  anterior  border  of  the  ramus  of 
the  jaw,  within  the  mouth,  down  to  the  anterior  fibres  of  the 
internal  pterygoid  muscle;  the  connective  tissue  between 
this  muscle  and  the  inner  surface  of  the  ramus  is  now 
pushed  aside,  and  the  nerve  detected  as  it  enters  the  canal. 
The  small  spine  surmounting  the  opening  for  the  entrance 
of  the  vessel  and  nerve  can  be  quite  readily  detected,  and 
will  be  a  valuable  guide  to  the  nerve  as  it  enters  the  dental 
canal.  It  can  now  be  isolated,  hooked  up,  and  divided. 
About  an  inch  and  a  half  can  be  easily  excised  in  this  situa- 
tion, if  after  its  isolation  a  strong  ligature  be  thrown  around 
it  and  tied.  It  can  then  be  divided  by  curved  scissors  as  it 
enters  the  canal;  traction  by  means  of  the  ligature  can  then 
be  made  which  will  not  only  draw  the  nerve  down  to  admit 
of  the  division  of  one,  but  also  aid  the  good  that  may  be 
derived  from  stretching  process. 

It  may  be  approached  in  this  situation  from  without  by 
making  an  incision  from  the  sigmoid  notch  to  the  angle  of 
the  jaw,  the  parotid  gland  is  turned  aside,  and  the  mas- 
seter  muscle  detached  from  the  ramus  sufficiently  to  allow 
the  application  of  a  trephine.  When  the  button  of  bone  is 
removed,  about  one  half  an  inch  of  the  nerve  can  be  isola- 
ted, exposed,  and  excised.  However,  this  is  not  a  suit- 
able substitute  for  the  internal  method. 

The  nerve  may  be  exposed  in  its  course  through  the 
body  of  the  jaw,  by  raising  the  soft  parts  upward,  and 
making  an  incision  through  them,  about  two  inches  in 
length,  beginning  in  front  of  the  facial  artery.  After  the 
bone  is  thoroughly  bared,  a  trephine  is  applied  in  two  or 
more  situations,  and  the  bone  removed  down  to  the  canal, 
when  the  intervening  portions  may  be  chiselled  out,  and  the 
whole  nerve  removed;  or  it  may  be  resected  at  each  open- 
ing. 

The  former  is  the  surer  course.  It  may  also  be  divided 
as   it  emerges  from  the  mental  foramen,  by  turning  the 


176  OPERATIVE   SURGERY. 

lower  lip  outward,  and  making  an  incision  at  the  junctioil 
of  the  buccal  fold,  about  an  inch  in  length,  in  the  line  of 
the  bicuspid  teeth  downward,  three  fourths  of  an  inch, 
when  a  careful  search  will  disclose  the  filaments  as  they 
escape  from  the  opening.  Seize  them  with  the  forceps, 
draw  them  slowly  and  carefully  out,  and  cut  them  off. 

The  Lingual  Nerve. — This  may  be  reached  in  two  situa- 
tions: I.  As  it  passes  just  below  the  insertion  of  the 
pterygo-maxillary  ligament.  2.  Beside  the  tongue  and 
sublingual  gland.  In  the  former,  the  mouth  is  opened 
widely,  and  the  fold  of  mucous  membrane  covering  the 
ligament  is  readily  seen  behind  the  last  molar  tooth.  The 
nerve  can  be  felt  just  below  the  insertion  of  the  ligament, 
and  close  to  the  tooth.  Make  an  incision  backward  from 
the  tooth  over  the  course  of  the  nerve,  about  one  inch  in 
length,  carefully  push  aside  the  submucous  tissue,  and  the 
nerve  will  appear  in  the  wound,  when  it  can  be  raised  and 
cut.  It  has  been  successfully  divided  on  several  occasions 
near  this  situation  by  entering  the  point  of  a  curved  bis- 
toury, three  fourths  of  an  inch  behind,  and  below  the  last 
molar,  cutting  downward  and  outward  to  the  bone  in  an 
imaginary  line,  extending  from  the  angle  of  the  jaw  to  the 
last  molar  tooth.  In  the  second  situation,  the  tongue 
should  be  drawn  forward,  and  to  the  opposite  side,  and  an 
incision  made  about  one  inch  in  length,  parallel  with  the 
tongue,  and  one  fourth  of  an  inch  from  the  attachment  of 
the  mucous  membrane  to  it;  push  aside  the  submucous 
tissue,  and  the  nerve  wall  be  readily  seen. 

Brachial  Plextis. — It  may  become  necessary  on  account  of 
a  severe  neuralgia  involving  the  branches  of  this  plexus,  or 
located  in  a  painful  stump,  to  exsect,  or  stretch  the  cords 
near  their  origin.  It  is  best  done  prior  to  its  division 
into  its  three  terminal  cords  ;  that  is,  where  only  two  cords 
are  found.  Place  the  patient  upon  the  back,  raise  the 
shoulders,  and  turn  the  head  backward  and  to  the  oppo- 
site side.  The  course  of  the  external  jugular  is  determined 
by  pressure,  just  above  the  clavicle.  Make  an  incision 
along  the  posterior  border  of  the  sterno-mastoid,  three 
inches  in  length,  extending  doAvn  to  the  clavicle  ;  a  second 
incision  of  the  same  length  is  now  made  from  this  point, 
along  the  upper  border  of  the  clavicle,  carefully  avoiding 
the  external  jugular  ;  turn  the  flap  upward  and  seek  for 
the  posterior  belly  of  the  omo-hyoid  ;  when  found,  draw  it 
upward  with  a  hook  or  ligature,  push  aside  the  loose  con- 


OPERATIONS   UPON  NERVES.  1 77 

nective  tissue,  and  the  two  cords  will  appear  located  above 
and  to  the  outer  side  of  the  third  portion  of  the  subclavian 
artery,  which  should  be  carefully  avoided.  The  inner  cord 
is  cautiously  hooked  up,  and  a  ligature  applied  to  it,  by 
which  it  can  be  raised  from  its  bed  and  divided  with  a  pair  of 
scissors  near  the  outer  border  of  the  scalenus  anticus  mus- 
cle; being  careful  to  avoid  the  muscle  and  the  phrenic 
nerve.  If  gentle  traction  be  made  upon  the  ligature  the 
distal  extremity  will  be  raised,  and  can  be  again  divided 
an  inch  or  so  from  the  point  of  the  first  section,  and  re- 
moved. The  second  or  outer  cord  is  then  divided  in  the 
same  manner, 

Musculo-ciitaneoiis  Nerve. — Make  an  incision  two  and  one 
half  inches  in  length,  between  the  biceps  and  the  supinator 
longus,  through  the  integument,  fascia,  and  aponeurosis; 
separate  the  muscles  and  the  nerve  will  be  readily  seen. 

Miisculo-spiral  Nerve. — This  can  be  exposed  in  two  situa- 
tions. I.  By  making  an  incision  about  four  inches  in 
length,  between  the  outer  border  of  the  triceps  and  the 
brachialis  anticus  muscles,  beginning  it  two  and  one  half 
inches  above  the  external  condyle.  Divide  the  fascia  on  a 
director,  separate  the  connective  tissue  with  the  handle  of  a 
scalpel  or  by  the  finger,  and  the  nerve  will  be  easily  found, 
2.  Make  an  incision,  three  inches  in  length,  in  the  space 
between  the  supinator  longus  and  the  brachialis  anticus 
muscle  ;  divide  the  fascia,  separate  the  connective  tissue 
beneath  it,  and  the  nerve  will  be  quickly  found. 

Mediafi  Nerve. — It  can  be  easily  exposed  in  its  course 
along  the  arm  and  lower  one  half  of  the  forearm  by  modi- 
fying either  of  the  incisions  for  ligaturing  the  brachial  to 
correspond  to  the  relations  of  the  nerve  to  that  vessel. 

In  the  forearm,  by  making  an  incision  about  three  inches 
in  length,  along  the  inner  border  of  the  tendon  of  the 
flexor  carpi  radialis,  beginning  about  two  inches  above  the 
wrist  joint.  Divide  the  tissue  in  the  usual  manner.  Sepa- 
rate the  tendons  of  the  flexor  carpi  radialis  and  palmaris 
longus,  when  the  nerve  will  be  discovered  emerging  from 
beneath  the  fleshy  fibres  of  the  flexor  sublimis  digitorum. 

The  Radial  a7id  Ulnar  Nerves — like  the  median  in  the  arm — 
can  be  reached  readily  through  the  same  incisions  employed 
to  ligature  the  vessels  referred  to  above. 

Great  Sciatic  Nerve. — This  is  best  exposed  just  after  its 
escape  beneath  the  lower  border  of  the  gluteus  maximus. 
Place  the  patient  on  the  abdomen  and   make  an   incision 


178  OPERATIVE  SURGERY. 

three  or  four  inches  in  length,  beginning  at  the  gluteal 
fold,  at  a  point  midway  between  the  tuber-ischium  and 
trochanter  major ;  divide  the  integument  and  fascia 
on  a  director,  separate  the  connective  tissue  with  the 
fingers  and  handle  of  the  scalpel  down  to  the  nerve.  It 
can  then  be  stretched  by  passing  one  or  two  fingers  around 
it,  and  making  firm  and  steady  traction  upon  it  for  a  min- 
ute or  so.  Division  or  exsection  can  be  done  easily  through 
the  same  opening.  The  wound  should  be  carefully  closed 
and  dressed  under  antiseptic  precautions. 

Internal  Popliteal  Nerve. — This  can  be  reached  by  the 
same  method  and  with  the  same  caution  as  the  popliteal 
artery.  It  is,  however,  less  deeply  situated  and  somewhat 
nearer  the  centre  of  the  popliteal  space  than  the  vessels. 
Extreme  caution  should  be  exercised  in  operating  upon  it, 
on  account  of  its  nearness  to  the  popliteal  vein,  which  lies 
beneath  it  and  to  its  inner  side. 

External  Popliteal  Nerve. — It  can  be  easily  reached  by 
making  an  incision,  two  or  three  inches  in  length,  along  the 
inner  side  of  the  tendon  of  the  biceps  cruris,  when  the 
nerve  can  be  readily  found  beneath  the  fascia,  surrounded 
by  fat. 

The  Small  Sciatic,  Anterior  and  Posterior  Tibial  Nerves 
can  be  exposed  through  the  incisions  adopted  in  ligaturing 
the  vessels  of  the  same  name. 

Internal  Sphenous  Nerve — is  given  off  from  the  anterior 
cryral  and  supplies  the  inner  surface  of  the  leg.  It  is  ac- 
companied by  a  vein  of  the  same  name  in  its  course  along 
the  leg.  It  can  be  reached  easily  in  many  situations,  but 
practically,  however,  it  is  best  exposed  at  the  inner  side  of 
the  knee,  where  it  escapes  beneath  the  sartorius,  and  in 
the  middle  of  the  leg.  In  the  former  situation  recognize 
the  tendon  of  the  sartorius.  Press  upon  the  internal  saphe- 
nous vein  above  this  point  to  distend  it,  make  an  incision 
two  inches  in  length  close  to  and  parallel  with  the  vein, 
draw  it  aside,  and  the  nerve  will  be  found  emerging  from 
beneath  the  tendons  of  the  sartorius  and  gracilis.  In  the 
middle  of  the  leg  make  an  incision  three  inches  in  length, 
parallel  with  the  properly  distended  vein,  which  should 
then  be  pulled  aside,  and  the  nerve  is  found  beneath  it. 

The  External  Saphenoiis  Nerve  arises  from  the  internal 
popliteal,  escapes  between  the  heads  of  the  gastrocnemius, 
pierces  the  fascia  below  the  middle  of  the  leg  and  becomes 
subcutaneous,  passes  down  on  the  fibular  side  of  the  poste- 


TENOTOMY.  I79 

rior  surface  to  the  malleolus,  accompanied  by  the  external 
saphenous  vein.  Distend  the  vein  by  pressure,  make  an 
incision  close  to  and  parallel  with  it,  near  the  border  of 
the  tendo-Achillis;  pull  the  vein  aside,  and  the  nerve  will  be 
seen  beneath. 

The  Plantar  Nerves. — T"hese  are  the  terminal  branches  of 
the  posterior  tibial,  and  are  given  off  just  after  the  nerve 
winds  around  the  internal  malleolus.  They  can  be  ex- 
posed by  making  an  incision  about  three  inches  in  length, 
beginning  just  in  front  of  the  centre  of  a  line  extending 
from  the  anterior  border  of  the  internal  malleolus  to  the 
inner  tuberosity  of  the  os-calcis,  and  extended  forward 
along  the  external  border  of  the  abductor  pollicis.  If  the 
space  between  the  short  flexor  and  the  abductor  be  now 
opened  at  the  posterior  portion,  the  nerves  will  be  found 
accompanied  by  the  arteries  of  similar  name. 

Perifieal  Nerve. — This  may  be  exposed  in  the  perineum 
of  the  male  by  making  an  incision  along  the  rami  of 
the  pubes  and  ischium,  in  the  same  manner  as  directed 
for  ligaturing  the  pudic  artery  at  this  situation.  In 
the  female  perineum  the  nerve  may  be  exposed  either 
by  an  incision  made  without  or  within  the  vagina.  In  the 
former,  make  it  through  the  superficial  tissues,  about  three 
inches  in  length,  in  the  groove  between  the  labium  and  the 
perineum,  just  inside  the  rami  of  the  pubes  and  ischium. 
The  nerve  is  surrounded  by  connective  tissue,  and  it  is 
difficult  to  find  it  in  this  situation  ;  however,  if  the  blade  of 
the  knife  be  turned  inward  and  the  outer  coats  of  the 
vagina  be  divided  down  to  the  inner  one,  the  nerve  will 
not  escape  section. 

It  is  more  easily  severed  from  without  the  vagina.  If 
the  finger  be  introduced  an  inch  or  more,  and  lateral  pres- 
sure be  made,  the  nerve  will  be  felt,  cord-like  in  character 
and  sensitive  to  touch.  Make  a  vertical  incision  through 
the  coats  of  the  vagina,  and  the  nerve  will  be  exposed  for 
division  or  excision. 


TENOTOMY. 


Tenotomy  consists  in  making  a  subcutaneous  division 
of  the  tendons  of  muscles  to  overcome  or  alleviate  a  defor- 


i8o 


OPERATIVE   SURGERY. 


mity.  In  order  to  accomplish  this  successfully,  the  exact 
location  of  the  offending  structure  must  be  known,  together 
with  its  important  contiguous  vessels,  nerves,  etc.  Many 
of  the  large  tendons  are  easily  located  by  their  natural 
prominence.  Others  that  ordinarily  lie 
concealed  become  apparent  if  contrac- 
tion has  occurred,  and  still  more  con- 
spicuous if  they  be  placed  upon  the 
stretch.  The  principles  governing  tenot- 
omy should  be  well  considered  ere  a 
tendon  be  divided,  otherwise  an  expedi- 
ent of  great  good  becomes  mischievous 
and  even  destructive  in  its  results.  Mus- 
cles and  fascia,  either  singly  or  conjointly, 
are  also  the  direct  causes  of,  or  may  be 
indirectly  connected  in  causing  deformi- 
ties. They,  too,  are  amenable  to  similar 
treatment. 

The  instruments  employed  are  few  in 
number  and  simple  in  character.     Figure 
i86a    represents    the   tenotomes    devised 
by  Dr.   L.  A.  Sayre.     They  are  excellent 
instruments  for  the  purpose. 

(Fig.  187,)     This  represents  the  ordinary  tenotome  found 
in  the  pocket-cases  of  the  day.     It  is  too  fragile  to  be  safely 


Fig.  186a. 


Fig.  187. 

employed  in  the  division  of  tissues  requiring  any  outlay 
of  force.  A  detailed  description  of  either  is  unnecessary, 
since  they  can  be  ordered  from  the  instrument-maker  by 
simply  naming  the  designer. 

The  blade  of  the  tenotome  used  for  dividing  fascia 
and  muscles  (Fig.  188)  is  of  necessity  much  longer  than 
either  of  the  former  ;  the  principles  embodied  in  it,  how- 
ever, are  substantially  the  same.     An  observance  of  the  fol- 


TENOTOMY. 


i8i 


lowing  simple  rules  will  obviate  the  possibility  of  doing 
violence  to  other  than  the  tissues  directly  concerned  in  the 
operation:  i.  Mark  the  handle  to  indicate  the  di- 
rection towards  which  the  cutting  edge  looks.  2.  A 
Carefully  note  the  length  of  the  blade,  that  it 
may  be  inserted  only  fa''  enough  to  divide  the 
contracted  tissues.  3.  Place  the  structure  to  be 
divided  upon  the  stretch  (Fig.  189).  Pinch  up,  or 
press  aside  the  skin  over  the  part  to  be  cut,  so 
that  when  it  is  released,  after  the  completion  of 
the  operation,  the  opening  will  not  correspond  to 
the  divided  tissues.  4.  The  blade  should  be  made 
aseptic  before  being  used.  5.  Pass  the  knife  blade 
fro7n  important  vessels  and  nerves.  6.  Insert  the 
blade  on  the  flat,  closely  to  the  surface  of  the  tis- 
sue to  be  divided;  turn  the  edge  towards  it,  and 
carefully  sever  it  by  a  guarded  sawing  motion, 
aided  by  pressing  the  tendon  upon  the  cutting 
surface  of  the  knife.  If  unguarded  force  be  used, 
the  tendon  and  its  superimposed  tissues  may  be 
divided,  which  will  seriously  complicate  the  recov- 
ery. 7.  Withdraw  the  blade  upon  the  flat,  follow- 
ing it  by  firm  pressure  upon  the  parts  with  the 
thumb,  which  should  finally  rest  upon  the  incision; 
this  will  press  out  all  blood  and  exclude  the  air. 
8.  Seal  the  wound  carefully  with  adhesive  plaster 
or  collodion;  or,  stitch  it  with  asepticised  silk,  and 
apply  the  antiseptic  dressing.  9.  Rectify  the  de- 
formity and  confine  the  part  to  which  the  tendon 
is  attached  until  repair  shall  have  commenced. 
10.  Avoid  the  division  of  a  tendon  as  it  passes 
through  its  sheath,  if  possible.  11.  Divide  the 
offending  tissue  at  the  point  of  greatest  forced 
prominence;  provided,  it  be  consistent  with  its 
relation  to  important  structures.  If  reflex  spasm 
results  from  "  point  pressure"  the  tendon  should 
be  divided;  and,  at  the  pressure-point  inciting 
the  reflex  action. 

Tenotomy  of  Upper  Extremities. — The  tendons  of 
the  flexors  sublimus  and  profundus  digitorum 
may  be  divided  by  a  transverse,  subcutaneous 
incision  carried  through  them  down  to  the  bone, 
at  about  the  middle  of  the  first  row  of  anatomical  phal- 
anges.    Antiseptic  precautions  should  be  observed   care- 


FlG.  188. 


l82 


OPERATIVE  SURGERY. 


fully  in  this  instance,  otherwise  severe  inflammation  of  the 
tendons  of  the  sheath  may  follow.  After  the  division  of 
the  tendons  reduce  the  deformity  and  keep  the  parts  quiet 
for  five  or  six  days,  till  the  danger  from  inflammation  has 
subsided,  when  they  may  be  cautiously  extended. 

Extensor  Communis  Digttomm. — The  tendons  of  this  mus- 
cle can  be  readily  divided  as  they  pass  along  the  carpus  or 
upon  the  dorsum  of  the  phalanges.  In  the  former  instance, 
pinch  up  the  skin,  pass  the  knife  beneath  the  tendon  as  be- 
fore directed,  and  cut  towards  the  surface.  They  may  be 
divided  by  passing  the  blade  above  the  tendons  and  cut- 
ting down  upon  the  bone.     On  the  dorsum  of  the  phalan- 


PlG.  189. 

ges  the  blade  should  be  passed  beneath  the  skin,  and  the 
tendons  divided  upon  the  bone.  In  the  division  of  the  ten- 
dons of  both  flexor  and  extensor  muscles,  the  joints  and 
palm  of  the  hand  above  the  transverse  line  should  be 
avoided,  also  the  course  of  the  veins  and  the  spaces  be- 
tween  the  metacarpal   bones. 

Extensors  prinii,  secundi,  and  ossis,  metacarpi  pollicis  tendons 
can  readily  be  made  prominent  by  forcible  extension  of 
the  thumb  in  the  living  subject,  with  the  forearm  midway 
between  supination  and  pronation.  The  primi  and  ossis 
tendons  form  the  inner  boundary  of  the  *'  snuff-box"  at 
the  apex  of  the  styloid  process  of  the  radius,  the  ossis  being 
the  innermost  of  the  two.  The  tendons  of  the  extensor 
secundi   form  its  outer  boundary.     They  can  be  divided 


TENOTOMY.  1 83 

in  this  situation  by  first  making  them  as  prominent  as  pos- 
sible, then  introducing  the  knife  beneath  from  the  anterior 
surface  of  the  wrist  and  cutting  towai'ds  the  integument. 
The  radial  artery  is  to  be  avoided  as  it  passes  beneath  them, 
and  likewise  the  radicle  of  the  radial  vein  as  it  crosses  the 
intervening  space. 

Flexor  Carpi  Radialis. — The  tendon  of  this  muscle  is 
situated  immediately  to  the  inner  side  of  the  radial  artery, 
at  the  lower  third  of  the  forearm,  and  can  be  readily 
divided  by  passing  the  knife  from  the  artery  beneath  the 
tendon. 

Flexor  Carpi  Ulnaris. — This  is  the  most  internal  tendon 
on  the  anterior  surface  of  the  forearm,  and  has  the  ulnar 
artery  at  the  outer  border.  It  can  be  easily  cut  by  passing 
the  knife  beneath  it,  from  without  inward. 

Biceps  Muscle  at  the  Forearm. — The  tendon  of  insertion  of 
this  muscle  may  be  divided  either  above  or  below  the 
giving  off  the  bicipital  fascia.  The  former  being  the 
safer.  Make  the  veins  in  the  region  prominent  by  con- 
stricting the  arm  above,  extend  the  forearm  to  make  the 
tendon  prominent  and  tense;  enter  the  knife  at  its  inner 
border,  pass  it  cautiously  between  it  and  the  brachial  artery, 
and  cut  upward,  being  careful  not  to  injure  the  distended 
veins. 

Latissimus  Dorsi. — The  tendon  of  this  muscle  may  be 
divided  separately  at  the  lower  border  of  the  axilla,  or  con- 
jointly with  that  of  the  teres  major,  a  short  distance  below 
their  insertion  into  the  humerus. 

In  either  instance  the  arm  is  forcibly  raised  to  render 
them  tense  and  prominent,  and  a  long  narrow-bladed  teno- 
tome is  inserted  along  the  anterior  border,  and  they  are 
carefully  severed  by  a  sawing  motion. 

It  may  likewise  be  divided  at  the  lower  angle  of  the 
scapula.  Make  the  muscle  tense  as  before,  pass  a  long 
strong  tenotome  beneath  it,  and  cut  carefully  outward; 
close  the  opening  with  a  compress. 

Tenotomy  in  the  Lower  Extremities:  Tibialis  Posticus. — The 
tendon  of  this  muscle  is  intimately  associated  with  the  de- 
formity talipes  varus.  It  runs  along  the  inner  border  of 
the  tibia,  behind  the  internal  malleolus,  in  a  separate 
sheath;  being  the  innermost  tendon  at  this  situation,  after 
leaving  the  internal  malleolus,  it  goes  beneath  the  calcaneo- 
scaphoid  articulation  to  its  insertions. 

In  the  normal  foot  it  lies  well  concealed  within  its  closely 


1 84  OPERATIVE   SURGERY. 

fitting  groove;  it  can  be  readily  outlined  between  the  tip  of 
the  malleolus  and  the  calcaneo-scaphoid  articulation. 

In  talipes  varus  it  is  raised  from  its  groove  and  be- 
comes more  prominent  above  the  tip  of  the  internal  mal- 
leolus, as  well  as  below  it.  It  can  be  divided  in  either 
situation,  but  is  better  done  at  a  point  about  one  and  a 
half  inches  above  the  tip  of  the  malleolus  in  the  adult,  and 
one  inch  in  the  child  or  infant.  The  tendon  is  made  tense 
by  strongly  abducting  the  foot,  and  the  knife  is  passed 
with  the  usual  precautions  between  the  posterior  border  of 
the  tibia  and  the  tendon;  the  division  is  made  by  cutting 
outward. 

The  section  between  the  tip  of  the  malleolus  and  the  cal- 
caneo-scaphoid articulation  is  not  advised,  on  account  of 
the  contiguity  of  the  ankle-joint  and  the  internal  plantar 
artery;  if,  however,  it  be  thought  advisable  to  operate  at  this 
situation,  the  foot  should  be  strongly  abducted,  and  the 
point  of  the  tenotome  carefully  insinuated  beneath  the 
tendon,  and  between  it  and  the  internal  plantar  artery;  the 
handle  is  then  depressed  so  as  to  carry  the  point  away  from 
the  joint,  and  the  section  be  made  from  within  outward. 

Flexor  Longus  Digito7-u7n. — The  tendons  of  this  muscle 
are  sometimes  productive  of  contraction  of  the  toes,  after 
the  correction  of  the  deformity  of  the  tarsus  caused  by  the 
tibialis  posticus.  It  lies  immediately  posterior  to  the  ten- 
don of  the  muscle,  behind  the  internal  malleolus,  and  is 
often  divided  by  the  same  cut  which  severs  this  tendon. 
It  can,  however,  be  divided  independently. 

If,  after  the  division  of  the  posticus  tendon,  the  influence 
of  the  flexor  longus  digitorum  be  objectionable,  it  may  be 
divided  by  introducing  the  tenotome  beneath  it  through 
the  same  incision,  and  cutting  towards  the  surface  as  be- 
fore. The  posterior  tibial  artery  and  its  venae  comites, 
which  in  the  adult  are  often  varicose,  in  this  situation  must 
be  carefully  avoided  by  pressing  them  outward  with  the 
finger.  If  from  contraction  of  the  toes,  unassociated  with 
deformity  due  to  the  tibialis  posticus,  it  be  deemed  advis- 
able to  sever  its  tendon,  the  posterior  tibial  vessels  must  be 
first  detected,  pushed  outward  by  the  thumb,  which  should 
then  be  pressed  firmly  between  them  and  the  tendons  at 
the  inner  side;  pass  the  tenotome  perpendicularly  through 
the  integument,  midway  between  the  posterior  margin  of 
the  tibia,  and  the  end  of  the  thumb;  carefully  insinuate  it 
between  the  tendons  of  the  posticus  and  the  flexor  longus 


TENOTOMY.  iS^ 

digitorum  down  to  the  borie,  turn  the  edge  upward,  and 
carefully  divide  it  towards  the  surface. 

Flexor  Longics  Pollicis. — It  may  become  necessary  to 
divide  the  tendon  of  this  muscle,  on  account  of  the  crippled 
action  of  the  foot  in  walking,  dependent  upon  undue  flex- 
ion of  the  great  toe. 

The  toe  should  be  forcibly  extended,  and  the  knife  care- 
fully inserted  beneath  it  at  the  point  of  its  greatest  promi- 
nence, which  will  be  at  the  anterior  and  inner  side  of  the 
foot.  The  instrument  must  always  be  passed  from  the 
planter  artery. 

Tendo-Achillis  is  the  most  prominent  tendon  of  the  human 
system,  and  is  divided  at  its  narrowest  portion.  The  pos- 
terior tibial  artery  is  at  the  front  and  inner  side,  but  suffi- 
ciently remote  to  be  secure,  if  ordinary  care  be  exercised. 
The  short  saphenous  vein  lies  superficially  and  closely  to 
its  outer  border. 

It  can  be  readily  divided  if  the  foot  be  forcibly  flexed,  to 
render  it  tense;  pinch  up  the  skin,  push  it  outward  to 
protect  the  vein,  enter  the  knife  beneath  it  from  within 
outward,  turn  the  edge  towards  the  tendon  and  carefully 
sever  it  with  a  sawing  motion  while  the  foot  is  firmly 
flexed  and  the  tendon  pressed  upon  the  edge  of  the  knife 
by  the  finger.  Great  care  is  necessary,  else  a  sudden 
giving  away  of  the  tendon  may  cause  the  knife  to  sever  the 
superimposed  tissues.  All  the  precautions  enjoined  in 
tenotomy  should  be  carefully  observed  in  this  instance. 

Peroneus  Lofigus  and  Brevis. — Their  tendons  pass  in  a 
common  groove  behind  the  external  malleolus,  and  are 
enclosed  by  the  same  sheath;  the  latter  being  the  most 
anterior.  It  leaves  its  fellow  after  passing  behind  the 
malleolus,  and  is  inserted  into  the  base  of  the  metatarsal 
bone  of  the  little  toe  on  the  outer  side.  The  longus,  after 
passing  behind  the  malleolus,  gains  the  sole  of  the  foot, 
enters  the  calcaneo-cuboid  groove,  and  is  inserted  into  the 
base  of  the  metatarsal  bone  of  the  great  toe  at  its  outer 
side.  The  tendon  of  either  may  be  divided  in  two  situa- 
tions: (i)  About  one  and  one  half  inches  above  the  tip  of 
the  malleolus:  (2)  three-fourths  of  an  inch  in  front  of  it. 
It  is  commonly  divided  in  the  first  situation.  They  can  be 
severed  connectedly  or  singly  in  either  situation. 

If  it  be  decided  to  sever  both  simultaneously  above  the 
malleolus,  seek  the  anterior  and  external  border  of  the 
fibula,  about  an  inch  and  a  half  above  its  tip,  pass  the  knife 


186  OPERATIVE  SURGERY. 

between  the  bone  and  the  tendons,  turn  the  edge  outward 
and  cut  towards  the  surface.  The  short  saphenous  vein 
should  be  pushed  inward  to  avoid  injury. 

If  either  be  divided  separately,  push  the  integument 
backward  with  the  thumb,  to  protect  the  vein,  then  push 
the  thumb  firmly  down  to  the  bone  behind  the  tendons; 
pass  the  tenotome  perpendicularly  midway  between  the 
end  of  the  thumb  and  the  external  border  of  the  fibula, 
carefully  insinuate  it  between  the  tendons,  after  which  it  is 
passed  outward  or  inward,  as  the  case  may  be,  beneath 
the  tendon  to  be  severed,  the  edge  turned  upward,  and 
the  division  made  as  in  the  preceding  instances. 

If  the  division  be  made  below  the  malleolus,  make  the 
tendons  tense,  enter  the  knife  about  one  half  or  three 
fourths  of  an  inch  in  front  of  the  tip  of  the  malleolus,  be- 
tween the  tendons,  when  either  or  both  may  be  divided. 

Tibialis  Afiticus. — This  muscle,  like  the  posticus,  is  of  im- 
portance in  connection  with  the  deformity  of  talipes  varus. 

It  is  the  innermost  tendon  of  the  leg  and  foot  on  its 
anterior  surface,  and  can  be  easily  outlined  unless  the  foot 
be  fat  and  chubby,  when  some  difficulty  may  be  experi- 
enced. 

In  well-marked  cases  of  talipes  varus  it  is  displaced  con- 
siderably to  the  inner  side,  and  if  the  foot  be  abducted 
will  become  quite  prominent.  It  is  best  divided  about  one 
inch  above  its  insertion  into  the  internal  cuneiform  bone. 
Make  the  tendon  tense,  pass  the  knife  from  without  inward, 
to  avoid  the  dorsalis  pedis  artery. 

Extensor  PropriusPollicis. — As  it  passes  across  the  dorsum 
of  the  foot,  it  can,  like  the  preceding,  be  quite  easily  dis- 
tinguished. It  may  become  necessary  to  divide  it  after  the 
division  of  the  extensors  of  the  tarsus,  on  account  of  its 
causing  undue  extension  of  the  great  toe.  The  toe  should 
be  forcibly  flexed,  and  the  tenotome  carried  beneath  it  from 
without  inward,  to  avoid  the  dorsalis  pedis  vessels. 

Extensor  Longiis  Digitorum. — The  tendons  of  this  muscle 
may  not  only  cause  an  obstinate  extension  of  the  toes,  but 
aid  in  maintaining  the  tarsus  in  a  state  of  forced  flexion. 
They  can  be  divided  separately,  as  they  pass  along  the 
dorsum  of  the  foot,  provided  either  require  it.  If  all  be 
cut  at  once,  it  is  done  by  flexing  the  toes,  entering  the 
knife  beneath  them,  a  little  below  the  bend  of  the  ankle, 
from  within  outward,  to  avoid  the  dorsalis  pedis  vessels. 

JPeroneus  Tertius. — This  ma}'  be   divided  along  with  the 


TENOTOMY.  187 

extensor  longus  digitorum,  of  which  it  is  a  part,  as  before 
described;  or  it  can  be  done  separately  before  its  insertion 
into  the  dorsum  of  the  metatarsal  bone  of  the  little  toe,  by 
extending  the  tarsus,  and  passing  the  knife  beneath  it, 
from  without  inward.  It  is  the  most  external  tendon  on 
the  dorsum  of  the  foot,  ir  front  of  the  external  malleolus. 

Biceps  of  the  Leg. — This  tendon  forms  the  external  ham- 
string, and  is  inserted  into  the  head  of  the  fibula  and 
tuberosity  of  tibia.  The  external  popliteal  nerve  is  located 
immediately  at  the  inner  side.  To  divide  it,  the  leg  should 
be  extended,  and  the  tenatome  passed  from  within  out- 
ward, beneath  the  tendon  about  an  inch  and  a  half  above 
the  head  of  the  fibula. 

The  inner  hamstring  tendons  are  the  semi-tendinosis,  semi-inem- 
branosus,  gracilis,  and  sartorius;  the  two  first,  however,  are 
the  ones  principally  concerned.  The  tendon  of  the  semi- 
tendinosus  is  felt  as  the  longest,  smallest,  and  nearest  to 
the  median  line  of  the  popliteal  space;  that  of  the  semi- 
membranosus is  internal  to  it,  somewhat  less  superficial, 
and  runs  parallel  with  it.  Either  of  these  tendons  can  be 
divided  by  extending  the  leg  to  make  it  tense,  and  entering 
the  knife  beneath  and  from  the  outer  side,  at  the  most 
prominent  portion,  and  cutting  towards  the  surface.  Their 
division  to  relieve  forced  flexion  will  not  always  admit  of 
complete  extension,  due,  among  other  things,  to  the  con- 
traction of  the  heads  of  the  gastrocnemius,  which  are  in- 
serted into  the  condyles  of  the  femur.  The  forced  extension 
of  the  leg  under  these  circumstances,  often  causes  a  tearing 
asunder  of  the  attachments  of  this  muscle,  especially  the 
inner  head,  which  is  larger,  stronger,  and  inserted  higher 
than  the  external.  The  hemorrhage  resulting  therefrom 
may  be  severe  enough  to  infiltrate  the  calf  of  the  limb,  even 
extending  througliout  the  popliteal  space.  The  liability  to 
this  rupture  and  consequent  bleeding  may  be  lessened,  if 
not  obviated,  by  first  dividing  the  tendo-Achillis;  or,  which 
is  perhaps  better,  by  first  dividing  the  hamstring  tendons, 
when,  if  the  foot  becomes  extended,  on  attempting  to 
straighten  the  limb,  the  tendo-Achillis  can  then  be  divided. 

The  Gracilis  and  Sartorius. — They  may  be  divided,  after 
forcible  extension  of  the  leg.  Pass  the  tenotome  close  at 
the  inner  side  of  the  tendon  of  the  semi-membranosus, 
between  it  and  the  gracilis,  depress  the  handle  outwards  or 
inwards  as  the  case  may  be  and  divide  these  structures 
towards  the  skin. 


1§8  OPERATIVE   SijilGERY. 

Quadriceps  Extensor  Tendon  may  be  divided  above  the 
patella,  by  making  an  incision  down  to  the  tendon  and 
parallel  with  it,  entering  the  point  of  the  knife  above  it, 
cautiously  and  with  a  sawing  motion  divide  the  tendon. 
A  careful  and  continuous  attempt  should  be  made  to  flex 
the  leg  while  the  tendon  is  being  cut,  that  its  deepest 
fibres  may  be  ruptured,  thus  avoiding  the  possibility  of 
entering  the  synovial  extension  of  the  knee-joint,  which  lies 
beneath  it.  However,  the  limb  should  not  be  flexed  fur- 
ther than  is  necessary  for  this  purpose,  and  after  the  divi- 
sion should  be  placed  in  a  comfortable  position  till  repair 
is  well  advanced. 

Pectineus. — This  muscle,  which  acts  as  a  flexor  and 
adductor  of  the  thigh,  may  require  division  on  account  of 
malposition  of  the  limb.  The  pelvis  is  steadied,  thigh  ex- 
tended and  adducted,  which  causes  the  fibres  to  become 
tense  and  prominent.  A  long-bladed  tenotome  is  then 
introduced  at  the  outer  border,  about  an  inch  below  its 
origin,  and  carried  inward  and  upward,  till  the  division 
is  complete.  The  internal  circumflex  artery,  which  runs 
between  the  psoas  magnus  and  the  outer  border  of  the 
pectineus,  is  the  only  vessel  of  any  size  exposed  to  injury. 
The  danger  to  this  is  obscure,  unless  it  arises  higher  than 
usual. 

Adductor  Longus  is  situated  further  to  the  inner  side  of 
the  thigh  than  the  preceding,  forming  the  inner  border  of 
Scarpa's  triangle.  It  is,  however,  located  on  about  the  same 
plane  as  the  pectineus.  It  is  tendinous  at  its  origin  from 
the  pubes,  and  can  be  easily  divided,  when  made  tense, 
by  passing  the  knife  beneath  its  outer  border,  and  cutting 
upward  and  inward. 

Tensor  Vagince  Femoris  can  be  severed  without  difficulty, 
by  introducing  a  long-bladed  tenotome  beneath  it,  from 
either  border  of  the  muscle,  about  an  inch  below  its  origin, 
and  cutting  towards  the  surface. 

Sartorius  forms  the  outer  boundary  of  Scarpa's  triangle, 
and  can  be  divided  by  making  its  fibres  tense,  by  strong 
abduction  ;  then  introducing  a  long  tenotome  beneath  it, 
by  way  of  its  anterior  border,  two  or  three  inches  from  its 
origin,  and  cutting  upward  towards  the  surface. 

Multifidus  Spince.  lies  on  either  side  of  the  spinous  pro- 
cesses, in  the  groove  formed  by  the  spines  and  transverse 
processes,  from  the  sacrum  to  the  axis.  It  is  quite  super- 
ficial i/i  the  sajcral,  region,  opposite  to  the  posterior  superior 


TENOTOMY.  189 

Spinous  process  of  the  ilium.  Raise  a  fold  of  skin  parallel 
with  the  long  axis  of  the  muscle;  pass  a  long-bladed  teno- 
tome from  the  spine  outward  to  the  outer  border  of  the 
muscle,  and  cut  towards  the  spine. 

Erector  spines  forms  the  principal  portion  of  the  muscular 
prominences  on  either  s'de  of  the  spine,  to  be  seen  in  the 
lumbar  region.  It  is  a  thick,  strong  muscle,  which  arises 
from  the  sacrum  and  contiguous  structures,  and  divides  at 
the  lower  border  of  the  last  rib,  into  the  longissimus-dorsi 
and  sacro-lumbalis,  which  are  inserted  into  the  angle  of  the 
ribs  and  the  transverse  processes  of  the  dorsal  vertebrae. 
The^erector-spinae  can  be  divided  by  a  long  tenotome  passed 
from  within  outward,  to  the  outer  border  of  the  muscle, 
just  below  the  last  rib,  and  carried  downward  and  in- 
ward towards  the  spine. 

Trapezius. — This  is  a  muscle  possessing  an  extensive  ori- 
gin. The  portion  which  arises  from  the  inner  third  of  the 
superior  curved  line  of  the  occipital  bone  is  often  divided, 
on  account  of  deviations  of  the  head. 

This  is  readily  accomplished  by  making  the  muscle 
tense,  and  severing  it  with  a  tenotome  entered  beneath  it, 
and  below  the  occipital  protuberance;  the  edge  turned  to- 
wards the  integument. 

Sterno-cleido-mastoid. — Division  of  this  muscle  is  often 
necessary  in  cases  of  wry  neck,  dependent  upon  abnormal 
muscular  force.  It  is  divided  at  its  lower  extremity,  either 
at  its  sternal  or  its  clavicular  attachment;  often  at  both. 
For  the  division  at  either,  the  muscle  is  put  on  the  stretch 
by  turning  the  head,  and  a  blunt-pointed  tenotome  passed 
beneath  it  from  the  outer  side,  about  a  half  inch  above  its 
insertion,  and  divided  towards  the  surface.  The  division 
of  the  clavicular  portion  may  be  ample  to  correct  the  de- 
formity; if  not,  the  sternal  portion  should  be  severed  in 
the  same  manner.  It  is  necessary  to  closely  hug  the  under 
surface  of  the  portions  to  be  divided,  else  the  deep  seated 
and  important  vessels  may  be  injured.  It  is  not  safe  to 
attempt  a  subcutaneous  section  of  the  muscle  above  this 
point,  on  account  of  its  relation  to  the  common  carotid 
artery,  and  the  internal  jugular  vein. 

Plantar  Fascia. — This  tissue  is  an  exceedingly  dense, 
white  fibrous  membrane  of  great  strength,  with  the  fibres 
arranged  longitudinally.  It  is  divided  into  three  portions: 
the  middle  and  two  lateral.  The  former  is  the  one 
especially  concerned  in  those  deformities  requiring  division. 


tQO  OPERATIVE  SURGERY. 

It  is  narrow  behind  and  attached  to  the  inner  turbercle  of 
the  os-calcis.  Broader  and  thinner  in  front,  and  divides 
into  five  processes  opposite  the  middle  of  the  metatarsal 
bones;  being  one  for  each  of  the  toes.  Each  of  these  pro- 
cesses divide  opposite  the  metatarso- phalangeal  articula- 
tions into  tw^o  slips,  which  embrace  the  sides  of  the  flexor 
tendons,  and  are  inserted  into  the  sides  of  the  metatarsal 
bones  and  the  transverse  ligament.  It  likewise  sends  pro- 
longations between  the  groups  of  the  plantar  muscles. 
This  fascia  serves  the  important  function  of  assisting  in 
maintaining  the  integrity  of  the  plantar  arch. 

It  is  divided  by  placing  it  upon  the  stretch,  and  passing 
a  tenotome  beneath  the  inner  border  of  the  most  prominent 
portion,  and  cutting  towards  the  sole.  The  deformity  is 
then  overcome  as  much  as  is  practicable;  and  the  foot  is 
placed  and  fixed  in  the  corrected  position. 

Palmar  Fascia. — Like  the  plantar  fascia,  this  is  divided 
into  three  portions:  two  outer  and  a  middle  part;  the  mid- 
dle division  being  the  one  of  special  significance.  It  is 
narrow  above,  and  attached  to  the  lower  border  of  the  an- 
nular ligament;  below  it  is  broad  and  thinner,  and  opposite 
the  heads  of  the  metacarpal  bones  divides  into  four  slips, 
one  for  each  finger.  Each  slip  subsequently  subdivides  into 
two  processes,  which  enclose  the  tendons  of  the  flexor  mus- 
cles, and  are  attached  to  the  sides  of  the  first  phalanx,  and 
to  the  glenoid  ligament.  This  fascia  is  intimately  con- 
nected with  the  integument  of  the  palm,  and  sends  vertical 
septa  between  its  muscles.  From  various  causes  it  may 
undergo  structural  changes,  which  result  in  contractions  of 
the  fingers  on  the  palm,  as  well  as  shortening  of  the  palm 
itself.  The  anatomical  arrangement  of  the  fascia  fully  ex- 
plains the  mechanism  of  the  deformity.  It  must  be  care- 
fully diagnosticated  from  paralysis  of  the  extensors,  also, 
contraction  of  the  common  flexors.  The  contracted  bands 
are  divided,  by  placing  them  on  the  stretch,  and  passing  a 
narrow  bladed  tenotome  beneath,  and  cutting  towards  the 
surface.  The  deformity  is  then  reduced,  and  the  rectified 
part  placed  in  a  fixed  position  until  danger  of  inflamma- 
tion has  subsided. 

The  fascia  in  other  situations  may  become  contracted, 
as  the  fascia  lata,  at  its  upper  or  lower  extremities.  When- 
ever these  contractions  -cause  a  persistent  deformity  they 
should  be  divided,  and  upon  the  same  principles  as  like 
tissues  in  other  portions  of  the  body.     The  employment  of 


OPERATIONS   ON   BONES.  I9I 

an  anaesthetic  is  advisable  in  tenotomy,  especially  when 
the  section  is  to  be  extensive  or  contiguous  to  important 
structures. 


OPERATIONS  ON  BONES. 

The  injuries  and  diseases  to  which  bones  are  liable,  al- 
though not  differing  in  any  essential  particular  from  the 
same  conditions,  when  occurring  to  the  soft  parts,  require 
an  independent  consideration,  on  account  of  their  dissimi- 
larity of  function  and  structure.  Tendons,  muscles,  nerves, 
and  fascia  are  divided  and  resected;  so  is  bone.  The  in- 
tegument and  soft  parts  generally,  become  the  seat  of 
inflammation,  ulceration,  and  gangrene.  Bony  tissue  is 
likewise  preyed  upon  by  the  same  morbid  processes; 
named,  however,  quite  differently:  ulceration  of  the  soft 
parts  being  comparable  to  caries  of  bone;  necrosis  of  bone 
finds  its  synonym  in  gangrene  of  soft  parts.  To  preserve 
the  function  of  a  tissue  unimpaired,  is  the  greatest 'end  that 
can  be  attained.  To  relieve  a  patient  of  the  local  effects  of 
an  injury,  or  disease,  and  keep  him  in  possession  of  his 
natural  endowments,  constitutes  conservative  surgery  in 
its  fullest  sense. 

The  functions  of  bones  being,  in  a  practical  sense,  to  sup- 
port the  body,  protect  important  organs,  and  act  as  levers 
for  purposes  of  prehension  and  locomotion,  we  have  but 
to  act  with  a  knowledge  of  these  facts,  and  of  the  methods 
to  maintain  them,  to  give  to  the  patient  the  full  benefit  of 
our  art. 

The  operations  upon  bone  are  denominated,  gouging, 
sequestrotomy,  exsection,  osteotomy,  and  osteoplasty. 

Gouging  is  applied  to  the  removal  of  carious  bone,  and 
should  not  be  attempted  until  the  process  has  become 
chronic. 

The  instriimenfs  required  to  meet  the  exigencies  of  a  case 
are  gouges  (Figs.  189^;,  190,  191,  and  192),  scoops,  and 
chisels  (see  Figs.  180,  iSi,  182,  and  183),  of  various  sizes 
and  shapes,  together  with  a  suitable  mallet. 

Operation. — Having  arranged  the  patient  suitably  for  the 
convenience  of  the  operator,  administer  an  ansesthetic,  ap- 
ply the  elastic  bandage,  carrying  it  lightly  over  the  site  of 


tgi 


OPERAtiVE  SURGERY; 


the  disease,  make  a  free  incision  down  upon  the  carious 
bone,  separate  the  soft  parts  with  retractors;  and,  with  the 
drills,  gouge,  etc.,  remove  all  the  diseased  structure. 

It  is  important  to  be  able  to  determine  the  line  between 
the  healthy  and  diseased  bone;  and  this  is  often  very  diffi- 
cult.    If  the  portions  removed,  when  washed,   present   a 


m 


Fig. 


Fig.  igo. 


Fig.  191. 


Fig.  192. 


whitish,  grayish,  or  blackish  appearance;  are  porous  and 
fragile,  instead  of  being  vascular,  red,  and  tough,  then  the 
operation  should  be  continued.  If  the  gouged  surfaces 
bleed  freely  from  numerous  points,  and  have  a  normal 
firmness  and  color,  then  the  operation  should  cease. 

It  is  important  in  gouging  the  extremities  of  bones  to 
use  extreme  caution,  or  the  joint  cavity  may  be  opened 


SEQUESTROTOMY. 


193 


directly,  or  become  secondarily  involved.  After  the  re- 
moval of  the  elastic  constriction,  all  bleeding  should  be 
stopped;  the  wound  washed  thoroughly  with  a  suitable  an- 
tiseptic solution,  good  drainage  secured,  the  parts  united, 
and  dressed  antiseptically. 


SEQUESTROTOMY. 

This  operation  is  employed  to  remove  dead  bone  en  masse, 
therefore  applicable  to  necrosis.  The  additional  instru- 
ments necessary,  are  small  crowned  trephines,  bone-cutting 
forceps  of  various  shapes  (Figs.  193,  194  and  195),  gnawing 


Fig.  194. 


Fig.  195. 


Fig.  X93. 

forceps,  small  saws,  (Figs.  196  and  197),  periosteal  elevator, 
(Fig.  198),  etc.     There  are  two  methods  employed,  depend- 
ing on  the  nature  of  the  case,  viz.:  direct  and  indirect. 
The  Direct. — Having  detected  the  situation  of  necrosed 


194 


OPERATIVE   SURGERY. 


bone,  and  being  satisfied,  either  from  the  long  course  of 
the  disease,  or  by  movement  of  the  dead  portion,  that  de- 
tachment has  occurred,  apply  the  elastic  bandage,  using 
care  not  to  force  deleterious  matters  into  the  circulation, 
select  a  strong  knife  (Fig.  199),  and  connect  the  fistulous 
openings  with  each  other,  down  to  the  bone;  selecting  such 
openings,  of  course,  as  will  cause  the  connecting  incision  to 
be  consistent  with  good  drainage,  easy  access  to  the  dis- 


^^^j^^m^smmss^^^^^^l^z 


.t.UAAMATHUMIAn/wiMUUUMMJtl 


ifllUt>UVMII 11^ 


Fig.  197. 


Fig.  198. 


Fig.  196. 

eased  parts,  and  safety  to  the  underlying  structures.  The 
surfaces  of  the  incision  should  now  be  separated  with  re- 
tractors, to  fully  expose  the  openings  in  the  involucrum 
(Fig.  200).  If  the  sequestrum  can  be  drawn  out  of  the 
opening  with  suitable  forceps,  it  should  be  done  carefully; 
otherwise  the  reparative  tissue  upon  which  it  rests  will  be 
injured,  and  the  process  of  recovery  deterred.  If  it  be  too 
large,  or  be  interlocked  with  healthy  bone,  the  opening 
m  Jst  be  enlarged  sufficiently  to  admit  of  its  withdrawal;  or^ 


SEQUESTROTOMY. 


195 


if  this  be  impracticable,  an  incision  through  the  periosteum 
should  be  made,  corresponding  to  the  long  axis  of  the 
sequestrum.  The  periosteum  should  be  carefully  raised 
upon  either  side  of  the  incision  sufficiently  to  permit  the 
application  of  a  small  crowned  trephine,  with  which  the  in- 
volucrum  should  be  perforated  a  sufficient  number  of  times, 
to  admit  the  easy  removal  of  the  dead  portion;  either  with 
or  without  the  chiselling  away  of  the  irregular  borders. 
The  gnawing  forceps  (see  Fig.  179),  chisels,  and  mallet, 


Fig.  199. 


Fig.  199a. 


Fig.  20a 


and  even  the  small  saws  may  be  used  in  lieu  of,  or  in  con- 
junction with  the  trephine. 

If  there  be  but  one  sinus,  and  evidences  of  disease  exist 
above  and  below  it,  the  centre  of  the  incision  should  corre- 
spond to  the  sinus,  if  the  anatomical  relations  will  admit  of 
it.  Much  caution  is  often  essential  in  making  these  in- 
cisions in  the  vicinity  of  joints,  or  their  synovial  pouches 
will  be  opened.  After  the  removal  of  the  dead  bone,  the 
wound,  through  its  whole  extent,  should  be  thoroughly 
cleansed,  suitable  drainage  provided,  the  lips  of  the  wound 
closed,  and  antiseptic  dressing  applied;  or,  after  washing  it 
can  be  lightly  filled  with  oakum  saturated  with  balsam  of 


196  OPERATIVE   SURGERY. 

Peru,  or  carbolic  acid  and  oil,  and  the  whole  confined  in 
place  by  a  mass  of  carbolized  oakum,  held  in  position  by  a 
roller  bandage.  In  the  latter  instance  it  should  be  dressed 
frequently  to  secure  proper  cleanliness.  If  the  antiseptic 
plan  be  employed,  the  rules  applicable  to  the  method  should 
be  carried  out.  When  the  portion  of  bone  removed  is  large, 
or  the  remaining  part  is  small  and  fragile,  the  limb  must 
always  be  supported  by  a  splint;  otherwise  it  may  bend  or 
break,  and  thereby  complicate  the  ultimate  prognosis. 

If  the  sequestrum  be  as  yet  unseparated  from  the  healthy 
bone,  it  should  be  allowed  to  remain  until  the  process  of 
separation  is  completed,  when  it  can  be  removed. 

The  ifidirect  method  is  preferable  when  the  bone  is  super- 
ficial and  its  disease  progressive,  as  in  periostitis  of  the 
lower  jaw,  clavicle,  bones  of  the  arm,  forearm  or  tibia; 
in  fact,  all  the  long  and  many  of  the  flat  bones  can  be  re- 
produced by  this  method.  It  consists  in  making  a  free 
incision  down  upon  the  diseased  bone,  through  the  sur- 
rounding periosteum,  and  separating  the  membrane  by 
means  of  the  handle  of  a  scalpel,  spatula,  periosteal  ele- 
vator, or  any  instrument  of  a  like  character.  This  must 
be  done  at  intervals,  and  not  extend  beyond  the  diseased 
portion;  the  length  of  the  intervals  will  depend  entirely 
upon  the  rapidity  of  the  morbid  process.  This  plan  is  neces- 
sarily tedious,  both  in  detail  and  in  time;  yet  sooner  or 
later  the  dead  bone  can  be  raised  from  its  new  osseous 
trough,  which  will  soon  become  filled,  and  serve  the  pur- 
poses of  its  predecessor.  The  free  incision  necessary  to 
expose  the  dying  bone  will  provide  good  drainage;  other 
than  this,  it  should  be  kept  clean  by  ordinary  means. 

Excision. — Excision  of  bone  is  a  conservative  operation, 
directed  to  the  extraction  of  such  portions  of  it  as  are 
inconsistent  with  its  future  usefulness  or  the  symmetry  of 
the  patient,  together  with  the  removal  of  the  condition 
directly  demanding  the  operation.  It  is  employed  in  lieu 
of  the  more  radical  measure — amputation.  It  may  be 
directed  to  the  articular  extremities  or  to  the  shaft  of  a 
bone;  and,  in  either  instance,  it  vn.Q.y  he  partial  or  co7njlete. 
The  articular  extremities  or  joints  are  excised  on  account 
of  injury,  disease,  or  anchylosis  in  a  faulty  position.  In 
estimating  the  prognosis  for  life,  the  surroundings  of  the 
patient,  his  previous  habits,  present  condition,  and  the  ex- 
istence of  constitutional  taints,  must  be  considered;  also,  the 
nature  and  extent  of  the  cause  demanding  it.    The  prospec- 


EXCISION   OF  BONES.  I97 

tive  usefulness  of  the  limb  will  depend  on  the  ability  to 
leave  the  muscular  attachments  intact;  also  the  condition 
of  the  nerv-es  that  animate,  and  the  blood-vessels  that  nour- 
ish them.  If  the  patient  be  a  manual  laborer,  or  be  one  over- 
sensitive of  a  deformity,  it  is  well  then  to  consider  if  ad- 
ditional advantages  can  be  derived  from  artificial  limbs 
and  appliances;  when,  it  may  be  deemed  the  wiser  to  rele- 
gate the  offending  member  to  the  relief  afforded  by  amputa- 
tion. The  incision  preparatory  to  the  necessary  exposure  of 
the  parts  to  be  removed  should  be  free,  and,  when  possible, 
be  made  in  the  long  axis  of  the  bone.  They  are  often,  how- 
ever, varied,  to  suit  the  peculiar  demands  of  the  individual 
cases.  They  are  likewise  varied  for  the  different  joints, 
being  in  one  instance  longitudinal,  in  another  U,  H,  or  - 

shaped,  according  to  the  proposed  extent  of  the  operation 
and  the  contiguous  anatomy  of  the  part.  In  every  instance, 
however,  they  should  be  made  with  view  to  good  drainage, 
when  the  same  incision  will  render  the  parts  accessible,  and 
not  expose  adjacent  important  structures  to  unwarranted 
danger.  The  future  usefulness  being  one  of  the  most  im- 
portant factors  to  be  gained,  the  insertion  of  all  muscles, 
having  especially  defined  functions,  as  fiexion  or  extension, 
must  be  religiously  respected.  If  it  be  necessary  to  divide 
tendons,  it  should  be  done  obliquely;  the  better  to  facil- 
itate subsequent  union.  If  it  be  necessary  to  remove 
the  bony  surfaces,  into  which  they,  or  the  ligaments  are  in- 
serted, the  periosteum  covering  these  surfaces  should  be 
carefully  peeled  off,  along  with  the  tendinous  attachments. 
All  diseased  and  loose  pieces  of  bone  should  be  removed, 
together  with  irregularities  and  isolated  portions  of  artic- 
ular cartilages.  The  synovial  membrane  should  be  pre- 
served, unless  it  be  diseased;  and  its  diseased  portions  be 
cut  or  scraped  off.  The  removal  of  the  entire  shaft  of  a 
bone  may  be  necessary  on  account  of  injury  or  disease, 
notably  the  latter.  In  such  cases  the  incision  should  be  a 
•free  one,  and  be  made  over  its  most  superficial  aspect,  pro- 
vided that  important  structures  do  not  intervene ;  the 
periosteum  is  then  removed  proportionately  to  the  extent 
of  the  disease,  gradually  or  rapidly,  as  the  circumstances 
indicate,  and  the  diseased  bone  removed,  leaving,  if  pos- 
sible, the  epiphyseal  extremities.  If  the  epiphyseal  carti- 
lage be  destroyed  the  growth  of  the  bone  in  its  long  axis 
will  be  interrupted.  This  is  very  important  to  observe  in 
operations  upon  the  bones  of  adolescents,  since  to  destroy 


198 


OPERATIVE  SURGERY. 


this  cartilage  will  cause  a  subsequent  shortening  of  the 
limb.  The  consultation  of  any  standard  work  on  anatomy 
will  enable  the  surgeon  not  only  to  accurately  locate  the 
epiphyseal  junctions,  but  likewise  inform  him  of  the  age  at 
which  the  shafts  become  united  to  their  epiphyses. 

The  tt?ne  of  operating  must  be  governed  by  the  condition 
of  the  patient,  and  also  the  part  to  be  operated  upon.  If 
the  patient  be  suffering  from  shock,  reaction  should  take 
place  prior  to  operative  interference.  If  inflammation  of 
the  bone  occurs,  good  drainage  should  be  established,  and 
the  operation  deferred  until  it  subsides.  If  for  necrosis,  the 
diseased  bone  should  have  separated  before  the  attempt  is 
made. 

The  instruments  required  for  resection  are  varied  in  num- 
ber and  shape,  and  must  be  selected  according  to  the 
peculiarity  of  the  case.  The  knives  should  be  broad  and 
strong  (see  Fig.  199).  The  retractors  (see 
Fig.  200)  must  likewise  be  strong  and  pos- 
sess a  hook-like  curve,  otherwise  they  will 
slip  from  the  wound.  A  sharp-pointed  one 
may  be  employed  (Fig.  201).  The  peri- 
osteotome,  or  elevators  (Fig.  202),  vary  in 
shape;  but  should  possess  a  blunt,  non- 
cutting  edge;  if  compactness  be  desired,  it 
may  be  connected  with  the  handle  of  the 
knife  (see  Fig.  1991a!).  However,  it  is  not  so 
handy  or  efficient  as  the  independent  in- 
strument. They  must  be  used  with  care, 
otherwise  the  function  of  the  periosteum 
will  be  destroyed,  and  may  even  be  fol- 
lowed by  sloughing.  The  bone-cutting  in- 
struments are  forceps,  saws  of  various  sizes 
and  shapes.  The  straight  bone  forceps  are 
the  most  available  for  general  purposes. 
The  blades  should  fit  accurately,  and  be 
sufficiently  sharp  to  make  as  clean  a  cut  as 
possible.  In  order  that  bone  intricately 
located  may  be  reached,  the  blades  are 
bent  at  various  angles.  The  gnawing  for- 
ceps or  ronguer  are  of  inestimable  value  in  removing  bony 
projections. 

Bone-holding  Forceps  (Fig.  203)  vary  much  in  their  grasp- 
ing and  holding  powers;  consequently,  the  surgeon  will 
be    governed    in   his   selection   of  an    instrument   by  its 


Fig.  201.      Fig.  202. 


EXCISION   OF  BONES. 


199 


w.  r.  roPvD 

Fig.  206. 


200 


OPERATIVE  SURGERY. 


suitability  for  the  purpose.  The  varieties  of  saws  are 
numerous,  among  which  are  the  chain  saw  (Fig.  204V 
the  straight  saw,  with  an  adjustable  back  (Fig.  206); 
and  the  curved,  for  right  and  left 
sawing.  These  are  of  use  in  re- 
moving portions  of  thin  bones  from 
fiat  surfaces.  The  chain  saw,  as 
the  name  indicates,  is  composed  of 
numerous  links  or  sections,  having 
attached  to  each  extremity  a  han- 
dle for  working  it.  To  apply  the 
saw,  remove  the  handle  from  the 
hooks  and  carry  it  beneath  the 
bone  by  means  of  a  thread  and 
curved  needle,  with  the  cutting 
edge  upward,  or  an  instrument 
known  as  the  "  chain-saw  carrier" 
may  be  employed  instead  (Fig. 
205),  readjust  the  handle,  and  draw 
it  from  side  to  side  at  an  angle  of 
about  45°  with  the  bone.  It  should 
not  be  jerked,  or  be  allowed  to 
kink,  for  fear  of  clamping  or 
breaking  it.  This  instrument  is 
employed  in  dividing  those  bones 
which  are  nearly  surrounded  by 
the  soft  parts.  Fig.  207  repre- 
sents a  saw  of  great  practical 
worth.  The  blade  is  adjustable, 
and  its  cutting  surface  can  bte 
turned  in  any  direction  ;  it  has 
therefore  a  universal  application, 
which  renders  it  superior  to  the 
chain  saw,  except  in  isolated 
cases.  The  gauges,  chisels,  and 
mallet  are  required  to  thoroughly 
remove  all  diseased  bone.  They 
vary  in  size  and  shape,  in  order 
that  the  intricacies  of  the  wound 
may  be  reached.  The  instru- 
ments to  seize  the  fragments  of 
bone  are  also  variously  turned,  to  be  better  able  to  grasp 
them. 

Treatment  of  excision  wounds  is  in    nearly  all  instances 


Fig.  207. 


EXCISION  OF  BONES.  20l 

substantially  the  same.  Rest  and  thorough  drainage,  to- 
gether with  strict  antiseptic  measures,  constitute  the  basis 
of  the  future  treatment.  Rest  can  be  secured  by  the  various 
forms  of  splints,  either  movable  or  immovable  in  character. 
The  common  dressing  of  the  wound  consists  of  oakum, 
lint,  marine  lint,  or  a  fin-^  silken  oakum,  either  with  or  with- 
out saturation  with  carbolic  acid  and  oil,  or  balsam  of 
•Peru.  The  wounds  should  be  dressed  with  sufficient  fre- 
quency to  prevent  any  septic  infection,  once  daily  being 
usually  enough.  If  the  antiseptic  methods  be  adopted,  the 
rules  governing  their  readjustment  should  be  enforced. 

Excision  of  the  Upper  Jaw. — This  operation  is  done  for 
various  purposes,  connected  either  with  the  bone  structure 
itself  or  the  cavities  with  which  it  is  associated.  In  all 
instances  the  periosteum  should  be  preserved,  except  in 
such  as  are  associated  with  malignant  diseases. 

The  special  instruments  requisite,  in  addition  to  those  al- 
ready enumerated  for  exsections,  are  a  trephine,  or  a  bone 
drill  and  a  strong  pair  of  forceps  to  turn  out  the  bone,  to- 
gether with  forceps  to  draw  the  teeth  in  the  line  of  section. 
The  patient  is  anaesthetized  and  placed  upon  the  back, 
either  with  the  head  slightly  raised  or  markedly  depressed. 
In  the  latter  the  blood  does  not  escape  into  the  larynx,  but 
into  the  upper  and  posterior  part  of  the  pharynx.  This 
position,  however,  impedes  respiration  by  undue  stretching 
of  the  tissues  of  the  anterior  cervical  region.  However, 
this  may  be  obviated  in  a  great  degree,  if  the  front  of  the 
table  be  raised,  as  in  the  reduction  of  the  abdominal  con- 
tents by  taxis.  If  the  head  be  elevated,  the  blood  can,  with 
care,  be  kept  from  the  larynx,  either  by  constant  sponging 
or  tamponning  the  pharynx  around  a  large  catheter  or 
rubber  tube,  or  allowing  the  patient  sufficient  consciousness 
to  dislodge  it.  Still  another  method  is  to  confine  the  pa- 
tient in  a  rocking-chair,  which  can  be  tipped  forward  or 
backward  as  circumstances  require.  The  surest  of  all  is  to 
perform  a  preliminary  tracheotomy,  and  then  close  the  floor 
of  the  pharynx.  This  is  not  as  a  rule  necessary,  unless  the 
operation  be  complicated  with  a  very  vascular  morbid  pro- 
cess requiring  a  separate  removal.  If  the  important  asso- 
ciated anatomy  be  carefully  considered  before  beginning 
the  operation,  it  will  save  much  time  and  not  a  little  amount 
of  blood. 

In  complete  removal,  the  bony  connections  which  must 
be  divided  are:  i.  With  the  malar,  below  the  outer  angle  of 


202 


OPERATIVE  SURGERY. 


the  orbit;  2.  with  the  fellow  of  the  opposite  in  the  roof  of 
the  mouth;  3.  the  nasal  process  of  the  bone,  with  its  body 
below  the  inner  angle  of  the  orbit;  4.  the  slight  connection 
between  it  and  the  palate  bone  and  pterygoid  processes  of 
the  sphenoid.  The  internal  maxillary  in  the  spheno-maxil- 
lary  fossa  and  the  branches  of  the  facial  running  through 
the  external  soft  parts  are  the  only  vessels  that  will  cause 
troublesome  hemorrhage.  Steno's  duct  must  be  avoided, 
as  it  runs  from  the  parotid  gland  to  empty  into  the  mouth 
opposite  to  the  second  molar  tooth,  on  a  line  extending 


Fig.  208. 

from  the  lobe  of  the  ear  to  midway  between  the  border  of 
the  lip  and  the  ala  of  the  nose.  The  superior  branches  of 
the  seventh  pair  may  be  divided  unnecessarily,  if  the  course 
or  extent  of  the  incisions  be  too  great.  No  anticipated 
complication  should  be  permitted  to  occur.  Loss  of  blood, 
however,  is  the  only  one  outside  the  common  shock  of  all 
operations  that  requires  close  attention.  Haemorrhage  from 
the  facial  and  internal  maxillary,  while  often  profuse,  can 
be  easily  controlled. 

The  Lines  of  hicision. — They  may  be   made   within   or 
without  the  buccal  cavity. 


EXCISION  OF  BONES.  203 

To  attempt  the  removal  from  within  is  too  tedious,  the 
room  being  limited  and  the  ability  to  control  hemorrhage 
entirely  inadequate.  At  the  present  time  the  external  in- 
cisions are  the  only  practical  ones.  These  can  be  classed 
as  outer  and  median.  The  former  commencing  at  the 
angle  of  the  mouth  and  prssing  in  a  curved  course  upward 
and  outward  to  the  malar  process;  this  exposes  Steno's 
duct  and  the  branches  of  the  seventh  nerve  to  injury,  and 
is  followed  by  a  conspicuous  scar  (Fig.  208,  A).  The  lat- 
ter is  made  at  the  middle  of  the:  upper  lip,  and  following 
the  furrows  between  the  cheek  and  nose,  terminates  about 
one  half  an  inch  below  the  inner  angle  of  the  eye  (B).  To 
this  may  be  added  an  incision  of  an  inch  or  so  in  length, 
extending  outward  half  an  inch  below  the  orbit,  and  at  a 
right  angle  with  the  vertical  one.  In  this  incision  the 
coronary  and  angular  arteries  only  are  divided. 

Operation  by  tJie  median  incision,  with  removal  of  the  whole 
bone.  The  middle  incisor  tooth  corresponding  to  the  side 
to  be  operated  upon  is  drawn,  and  the  facial  artery  com- 
pressed on  both  sides  by  an  assistant.  The  incision  is 
begun  at  the  border  of  the  lip,  but  not  carried  through  it 
until  later,  to  prevent  blood  entering  the  mouth;  from  the 
upper  attachment  of  the  lip,  through  the  remainder  of  the 
course,  the  incision  is  rapidly  made  down  to  the  bone,  and 
the  flap  dissected  outward  as  far  as  the  malar  bone  above,  and 
the  tuberosity  of  the  maxilla  below;  during  the  dissection 
the  bleeding  points  are  controlled  by  the  fingers  of  the  as- 
sistant or  by  the  serrefine  forceps.  They  should  be  ligated 
with  catgut  before  the  bone  is  moved.  The  cartilage 
of  the  7wse  is  separated  from  the  bone  and  turned  in- 
ward, the  edge  of  the  orbit  gained,  and  the  periosteum  on 
the  floor  separated,  and  pushed  backward  and  upward  by 
means  of  an  elevator  or  handle  of  a  scalpel  to  the  border 
of  the  spheno-maxillary  fissure.  The  malar  process  is  now 
divided  by  sawing,  or  cutting  through  it  with  bone  forceps, 
from  the  outer  extremity  of  the  spheno-maxillary  fissure. 
The  thin  floor  of  the  orbit  is  divided  with  a  scalpel  from 
the  spheno-maxillary  fissure  obliquely  forward  and  in- 
ward, and  the  nasal  process  severed  with  forceps.  The 
mucous  membrane  of  the  roof  of  the  mouth  is  then  divided 
transversely  from  the  centre  inward,  on  a  line  with  the 
last  molar  tooth,  then  from  the  centre  forward,  in  the  median 
line,  to  the  incisor  teeth.  The  hard  palate  is  divided  at  the 
side  of  the  septum,  corresponding  to  the  bone  to  be  removed, 


204  OPERATIVE  SURGERY. 

by  a  saw  or  bone  forceps,  and  the  bone  seized  and  pressed 
downward  to  break  up  its  posterior  connections,  after  which 
it  is  raised  and  twisted  slightly  from  side  to  side  and  pulled 
out,  bringing  with  it  some  portix)ns  of  the  palate  and  ptery- 
goid process  of  the  sphenoid,  together  with  the  muscular 
fibres  connected  with  them.  If  the  mucous  membrane  of 
the  mouth  be  not  diseased,  it  can  be  saved  by  making  an 
incision  through  it  along  the  alveolar  border,  and  pushing 
it  inward  along  with  the  periosteum  to  the  median  line. 
After  the  removal  of  the  bone  it  can  be  stitched  to  the  side 
of  the  cheeks. 

JExsection  Below  the  Floor  of  the  Orbit. — After  the  exposure 
of  the  external  surface  of  the  superior  maxilla,  as  in  the  pre- 
ceding method,  perforate  the  anterior  wall  of  the  antrum 
with  a  drill  or  trephine;  then  with  the  bone  forceps  or  saw 
inserted  into  the  opening,  divide  the  bone  through  into  the 
nasal  fossa,  and  separate  it  from  its  outer  connections  by 
sawing  or  cutting  through  the  malar  bone.  Aside  from 
this  the  steps  of  both  are  similar. 

After  the  operation,  the  wound  is  washed  with  carbolic 
acid,  and  all  bleeding  points  checked  either  by  ligature, 
pressure,  or  cauter}^,  the  former  being  the  best.  The  ex- 
ternal incision  is  then  closed  with  sutures,  or  pins,  and 
readily  unites  in  three  or  four  days.  The  raw  surfaces 
within  should  be  kept  thoroughly  cleansed  while  repair  is 
taking  place.  These  cases  make  a  satisfactory  recovery 
from  the  operation,  although  some  deformity  will  remain. 

The  stitches  are  removed  from  the  soft  parts  the  third  or 
fourth  day,  union,  as  a  rule,  being  complete.  The  results 
of  this  operation  are  good,  so  far  as  immediate  loss  of  life 
is  concerned.  About  one  in  six  or  seven  will  perish.  If 
the  removal  be  done  for  malignant  growths,  the  prognosis 
for  ultimate  recovery  is  unfavorable. 

Subperiosteal  Excision. — This  can  be  done  with  any  of 
the  median  incisions,  but  an  external  one  is  preferred  by 
some  (Fig.  209).  The  external  incision  is  made  from  the 
middle  of  the  malar  bone  to  a  point  on  the  upper  lip,  one 
third  of  an  inch  from  the  angle  of  the  mouth.  It  is  some- 
times necessary  to  make  a  second  cut  from  the  middle 
of  the  lip  upward,  as  in  the  preceding  operation.  The 
mucous  membrane  on  the  external  surface  of  the  alveolar 
process  is  divided  down  to  the  bone:  beginning  at  the  line 
of  junction  between  the  lateral  incisor  and  canine  teeth 
and  carried   backward  to  and  around  the  posterior  molaf 


EXCISION   OF  BONES. 


205 


to  the  inner  surface  of  the  alveolar  process,  forward  paral- 
lel with  the  external  incision  to  a  point  opposite  the  com- 
mencement of  the  external,  then  obliquely  backward  and 
inward  on  a  line  corresponding  to  the  intermaxillary  su- 
ture of  that  side  to  the  median  line.  The  anterior  extremi- 
ties of  the  external  and  internal  incisions  are  now  connected 
to  each  other  by  a  transverse  one,  carried  on  a  line  extend- 
ing between  the  lateral  incisor  and  canine  teeth.  The 
periosteum  is  then  peeled  of  the  external  and  orbital  sur- 
faces of  the  bone,  and  also  from  the  inner  surfaces  of  the 
alveolar  process,  and  the  hard  palate  of  that  side.     The 


Fig.  209. 


nasal  and  malar  processes  are  divided  as  before,  the  canine 
tooth  drawn,  and  the  intermaxillary  bone  separated,  to- 
gether with  the  hard  palate  of  the  maxilla  to  be  removed, 
from  the  contiguous  bone,  by  a  chisel,  saw,  or  forceps. 
The  maxilla  is  then  twisted  out,  and  the  periosteum  from 
the  inner  and  outer  surfaces  of  the  alveolar  process  united. 
The  superior  maxillcz  may  be  removed  simultaneously  by  either 
of  two  methods,  i.  Make  an  incision  from  each  angle  of 
the  mouth  to  the  middle  of  the  malar  bone  on  the  re- 
spective  sides    (Fig.    210,  A),  and   dissect  upward  the  in- 


2o6 


OPERATIVE  SURGERY. 


tervening  flaps;  or,  2,  make  a  vertical  one  along  the  ridge 
of  the  nose  through  the  lip,  beginning  at  a  point  one  fourth 
of  an  inch  below  the  lower  border  of  the  orbit.  To  this 
maybe  added  a  transverse  one  extending  between  the  mid- 
dle of  each  orbit,  one  fourth  of  an  inch  below  it,  across  the 
upper  end  of  the  vertical  one,  B;  the  outer  bony  attachments 
are  divided  as  in  the  single  operation;  the  nasal  processes 
are  divided  either  by  forceps  or  the  saw,  and  both  bones 
removed  at  once — not  separately.  About  fifty  per  cent  of 
those  perish  from  whom  both  bones  are  removed  simul- 


FlG. 


taneously.  In  all  operations  for  the  complete  removal,  the 
superior  maxillary  nerve  should  be  divided  as  far  back  as 
possible. 

Excision  of  the  Inferior  Maxilla. — The  operations  on  the 
lower  jaw  require  no  additional  instruments,  and  the  pre- 
cautions referrible  to  the  patient  in  the  former  case  are 
almost  equal  in  importance  in  this,  and  the  contiguous 
anatomy  is  even  greater.  The  facial  artery  runs  beneath 
and  across  its  lower  border  and  outer  surface  at  the  ante- 


EXCISION  OF  BONES.  20^ 

rlor  border  of  the  masseter  muscle;  the  parotid  gland  lies 
behind  the  ramus,  and  often  sometimes  overrides  it.  The 
external  carotid  artery,  as  it  passes  through  the  gland,  is 
closely  associated  with  its  posterior  border.  The  internal 
maxillary  artery  passes  closely  behind  and  to  the  inner 
side  of  the  neck  of  the  condyle.  The  inferior  dental  artery 
runs  along  the  inner  surface  of  the  ramus  to  enter  its  canal. 
The  superior  division  of  the  seventh  pair  of  nerves  pass 
across  the  outer  border  of  the  neck  of  the  condyle.  Steno's 
duct  passes  across  the  masseter  muscle  to  the  opening  op- 
posite the  second  molar  tooth,  on  a  line  parallel  with  and  a 
half  inch  below  its  lower  border.  The  lingual  nerve  runs 
along  the  inner  surface  of  the  ramus,  close  to  the  bone  just 
below  the  last  molar  tooth. 

The  genio-hyo-glossus  muscle  is  attached  to  the  superior 
genial  tubercles,  and  if  incautiously  detached  will  permit 
the  tongue  to  fall  backward,  and  close  the  glottis.  It  is  very 
important,  when  possible,  to  respect  the  attachments  of  the 
muscles  of  mastication,  on  account  of  their  action  on  the 
resultant  tissues.  The  operation  may  be  directed  to  a  com- 
plete or  partial  removal  of  the  bone.  A  partial  removal 
may  include  any  fractional  portion  of  it. 

The  incisions  for  the  removal  may  be  made  within  the 
mouth  or  on  the  external  surface.  If  the  whole  or  a  lateral 
half  be  removed,  an  external  incision  must  be  made.  The 
portion  in  front  of  the  molar  teeth,  and  even  in  front  of  the" 
ramus,  can  be  excised  by  internal  incisions  alone;  the  latter 
is,  however,  often  attended  by  vexatious  difficulties,  and  is 
hardly  warrantable,  except  in  isolated  cases.  The  ramus 
and  portions  of  the  body  behind  the  teeth  can  be  removed 
through  an  external  incision  without  opening  into  the 
buccal  cavity,  provided  the  periosteum  be  carefully  raised 
from  its  surface.  In  the  same  manner  the  body,  or  any 
portion  of  it,  can  be  taken  away  if  the  teeth  be  absent.  If 
the  teeth  be  present,  the  periosteum  may  be  carefully  de- 
tached and  the  bone  with  the  teeth  removed;  after  which 
the  openings  into  the  buccal  cavity,  caused  by  the  with- 
drawal of  the  teeth,  can  be  closed  with  sutures  applied  in- 
ternally. If  the  jaw  be  suffering  from  phosphorous  or  a 
similar  necrosis,  it  may  be  gradually  enucleated  by  the  in- 
direct method,  through  an  external  opening,  from  its 
surrounding  involucrum,  and  the  teeth  may  even  remain 
in  the  new  growth.  Unfortunately,  however,  when  pro- 
cesses of  a  malignant  nature  call  for  the  operation,  these 


208  OPERATIVE  SURCERY. 

conservative  methods  are  of  no  avail,  since  the  Operation 
must  be  directed  to  the  removal  of  all  the  diseased  tissues. 
When  possible,  the  incisions  in  the  buccal  lining  should 
be  closed  and  the  wound  drained  externally.  This  will 
keep  the  wound  clean  and  prevent  swallowing  of  the  dis- 
charges. 

Excision  of  the  Central  Portion. — Pass  a  stout  ligature 
through  the  tongue  well  behind  its  tip,  to  prevent  tearing 
out,  and  tie  the  ends  to  form  a  loop,  which  will  be  conven- 
ient for  holding  it.  The  assistant  stands  behind  the  head 
of  the  patient,  holds  it  firmly,  at  the  same  time  compressing 
the  facial  arteries  wher^  they  pass  across  the  jaw;  or,  seizes 
the  lower  lip  at  the  angles  between  the  thumbs  and  fingers, 
rendering  it  tense,  and  at  the  same  time  arresting  its  circu- 
lation. The  operator,  standing  in  front,  makes  a  vertical  in- 
cision through  the  median  line  down  to  the  bone,  extending 
it  to  the  lower  border  of  the  symphysis  mentis,  raises  the 
periosteum  from  its  surfaces,  if  practicable,  to  the  extent  of 
the  proposed  section,  draws  a  tooth  at  each  point  where  the 
bone  is  to  be  divided,  saws  it  at  these  points,  and  draws  the 
fragment  forward,  and  separates  the  attachments  of  the 
muscles  as  closely  as  possible  to  their  insertion.  The  flaps 
are  then  united  with  silver  wire,  extending  through  the 
mucous  membrane.  The  vermilion  border  of  the  lip  is 
carefully  adjusted,  and  united  with  pins  or  silver  sutures. 
If  the  tongue  fall  backward,  its  severed  muscular  attach- 
ments can  be  drawn  forward,  and  connected  with  the  cut  in 
the  median  line  by  a  deep  suture  passed  through  the  lip.. 
The  bone  can  be  easily  reached  through  a  curved  incision, 
made  along  its  lower  border,  or  by  an  internal  one  cor- 
responding to  the  fold  of  the  buccal  membrane.  The  lip- 
is  depressed  over  the  symphysis  mentis,  and  the  bone  is  re- 
moved. 

Excision  of  the  Lateral  Portion  of  the  Body. — Make  an  ex- 
ternal incision  along  the  under  border  of  the  portion  to  be; 
removed,  down  to  the  bone.  If  necessary,  it  may  be  turned, 
upward  at  a  right  angle  towards  but  not  through  the  lip. 
If  the  condition  of  the  parts  will  permit,  the  periosteum  is 
reflected  off,  the  bone  divided  in  front,  external  to  the 
insertion  of  the  genio-hyo-glossis,  and  if  possible  turned, 
outward,  and  the  tissues  separated  back  to  the  point  of 
posterior  section;  it  is  then  removed  with  a  chain  saw,  and 
dressed  as  before. 

Mxcision  of  Half  of  the  Lower  Jaw. — Commence  the  in- 


EXCISION   OF  BONES.  209 

cision  about  an  inch  below  the  arch  of  the  zygoma,  and 
carry  it  downward  at  the  posterior  border  of  the  ramus, 
and  around  beneath  the  body  of  the  jaw  to  the  symphysis 
mentis,  carefully  exposing  the  facial  artery  and  tying 
it.  If  the  operation  be  for  necrosis,  this  incision  will  be 
sufficient  ;  if  for  other  disease,  the  lower  lip  is  cut  per- 
pendicularly through  its  centre  to  meet  the  longitudinal 
incision   (Fig.    211).     The   bone   is   exposed    in    front   by 


Fig.  211 

peeling  off  the  periosteum  or  otherwise,  and  sawn  through 
just  outside  the  insertion  of  the  genio-hyo-glossus  if  possi- 
ble, the  end  pulled  outward,  and  the  remaining  attached 
tissues  separated  either  by  cutting  or  by  a  periosteotome, 
back  to  the  beginning  of  the  incision.  Depress  the  frag- 
ment forcibly,  and  if  possible  detach  the  temporal  muscle 
with  scissors  or  osteatome,  then  turn  it  outward,  and  divide 
the  insertions  of  the  pterygoid  muscles  in  the  same  manner, 
carefully  avoiding  cutting  the  lingual  nerve,  draw  the  bone 
forward  forcibly  and  twist  it  from  its  socket. 

If  it   be   impossible   to  accomplish    its    removal    in   this 
manner,  extend   the  incision   upward   to  the  ne<:k  of  the 


210  OPERATIVE   SURGERY. 

bone,  avoiding  if  possible  the  division  of  Steno's  duct  and 
the  branch  of  the  seventh  pair  of  nerves,  and  enucleate  the 
condyle.  In  this  situation,  the  condyle  must  be  closely  fol- 
lowed, otherwise  the  internal  maxillary  artery  may  be  in- 
jured, as  it  passes  immediately  behind  it.  If  the  primary 
incision  be  sufficient  to  expose  the  bone  above  the  seat  of 
the  disease,  it  should  be  sawn  through  at  this  point  and  the 
upper  portion  allowed  to  remain. 

Excision  of  the  Entire  Lower  Jaw. — Remove  the  left  half 
first,  or  the  right  if  it  best  suits  the  convenience  of  the 
operator,  in  the  manner  before  described.  A  ligature  is 
then  passed  through  the  tongue,  given  to  an  assistant, 
and  the  remainder  exsected  in  a  similar  manner.  Stop  all 
hemorrhage,  and  close  the  wounds  with  sutures  in  such  a 
way  as  to  accurately  coapt  the  divided  buccal  borders. 

In  all  situations,  when  the  nature  of  the  disease  will  per- 
mit, the  periosteum  should  be  reflected  by  a  careful  yet 
vigorous  use  of  the  elevator.  The  insertion  of  ligaments 
and  tendons  only  will  afford  an  obstacle,  and  these  should 
be  carefully  detached  by  a  sharp  knife,  that  a  continuity  of 
the  periosteal  and  fibrous  tissues  will  remain. 

The  periosteum  in  young  subjects  may  reproduce  enough 
bony  material  to  give  a  fair  outline  to  the  face  and  serve  an 
important  function  in  mastication. 

If  bone  be  not  reproduced,  the  membrane  will  furnish  a 
firm  fibrous  base,  which  may  be  utilized  for  artificial  appli- 
ances. If  the  anterior  portion  of  either  or  both  sides  be 
removed,  the  gap  may  be  filled  in  by  an  artificial  dental  ap- 
pliance, which  will  often  happily  maintain  the  symmetry  of 
the  face  and  become  useful  in  mastication. 

Excision  of  the  Alveolar  Process. — When  the  extent  of  the 
disease  will  permit,  the  alveolar  process  can  be  removed 
down  to  the  body  of  the  jaw  through  either  an  external  or 
internal  incision,  the  former  being  the  better.  The  dis- 
eased part  is  then  removed,  and  the  wound  closed  as  be- 
fore. After  recovery,  the  body  of  the  jaw  will  form  an  ex- 
cellent foundation  for  a  compensatory  dental  appliance. 
Whenever  the  disease  is  malignant,  the  periosteum  should 
be  removed  with  the  bone,  and  care  taken  that  none  of  the 
diseased  membrane  remains  in  the  wound.  It  is  also  neces- 
sary in  such  cases  to  remove  all  associated  structures  when 
diseased — such  as  glands,  floor  of  the  mouth,  and  even  the 
tongue  itself. 

Results. — Out  of  246  exsections  in  the  continuity,  46  died. 


EXCISION   OF   BONES.  211 

Of  153  disarticulations  of  one  half  the  bone,  :^6  died.  In 
20  operations  for  removal  of  the  entire  jaw,  i  died.  It  will 
be  seen  that  death  has  followed  in  20  per  cent  of  all  the 
cases.  Pyaemia,  erysipelas,  and  exhaustion,  were  the  prin- 
ciple causes. 

Operation  for  Anchylos's  of  the  Inferior  Maxilla. — This 
consists  in  establishing  a  false  joint  in  front  of  the  cause 
of  the  immobility  which  is  usually  dependent  on  cicatricial 
contraction,  irreducible  dislocation,  and  anchylosis.  The 
removal  of  a  wedge-shape  piece  from  the  lower  border  of 
the  jaw  has  been  practised;  also,  from  the  alveolar  process; 
transverse  section  of  the  ramus  with  a  sharp  chisel  intro- 
duced through  the  mouth,  likewise,  fracture  of  the  neck 
when  the  condyle  is  involved. 

Operation  for  Removal  of  a  Wedge-shaped  Piece. — Make  an 
incision  two  inches  in  length  down  to  the  bone,  along  the 
lower  border  of  the  jaw,  beginning  at  or  in  front  of  its 
angle,  depending  upon  the  location  of  the  cause  of  the  im- 
mobility. Avoid  or  tie  all  important  vessels  in  the  course 
of  the  incision  ;  expose  both  surfaces  of  the  bone  up  to  the 
summit  of  the  alveolar  process,  and  pull  a  tooth  if  neces- 
sary. Divide  it  with  a  chain  saw  at  one  extremity  of  the 
exposed  surface,  force  the  other  extremity  through  the 
wound,  and  remove  the  wedge-shaped  piece  with  the  ron- 
geur or  saw,  the  base  of  which  should  not  exceed  a  third  or 
half  an  inch.  While  the  patient  is  still  under  the  influence 
of  the  anaesthetic  and  before  the  wound  is  closed,  ascertain 
the  distance  the  liberated  portion  can  be  separated  from 
the  upper  jaw  with  moderate  force.  Provide  suitable 
drainage,  close  the  wound,  and  prevent  union  of  the  bones 
by  passive  motion. 

Exsection  of  the  Stermtm. — No  definite  plan  for  this  opera- 
tion can  be  outlined.  The  form  and  length  of  the  incisions 
must  be  governed  by  the  location  and  extent  of  the  disease. 
The  diseased  bone  should  be  freely  exposed,  and  removed 
in  the  usual  manner.  Care  must  be  observed,  else  the 
pleural  cavity  will  be  opened.  When  possible,  subperios- 
teal excision  should  be  done,  as  the  bone  is  quite  readily 
reproduced. 

Excision  of  a  portion  of  a  Rib. — This  ma)'-  be  done  for  the 
removal  of  necrosed  bone,  or  to  make  a  permanent  opening 
into  the  thorax  for  the  escape  of  pus.  If  for  diseased  bone, 
make  an  incision  in  the  middle  of  its  long  axis  of  sufficient 
length  to  include  the  diseased  portion.   This  may  be  crossed 


212  OPERATIVE   SURGERY. 

at  the  middle  by  a  transverse  incision.  Separate  the  perios- 
teum along  with  the  superimposed  tissues,  liberate  the  bone, 
and  raise  it  from  its  bed.  If  the  sequestrum  be  not  loose, 
time  should  be  allowed  for  its  separation.  If  the  operation 
be  for  pyo-thorax,  select  the  sixth  or  seventh  rib;  make  an 
incision  about  two  or  three  inches  in  length  down  upon  its 
middle,  through  the  periosteum  in  a  line  with  the  axilla, 
bisect  this  by  a  horizontal  one  the  width  of  the  rib,  expose 
the  bone  on  both  surfaces  by  raising  the  periosteum  along 
with  its  surrounding  tissues,  being  careful  as  yet  not  to 
open  into  the  pleural  cavity;  exsect  one  half  or  three  fourths 
of  an  inch,  dividing  it  with  a  chain  saw.  If  the  intercostal 
artery,  which  lies  beneath  its  lower  border,  be  cut,  tie  it; 
then  make  a  suitable  opening  through  the  intervening  struc- 
tures into  the  pleural  cavity. 

It  is  well  to  make  the  first  incision  for  the  purpose  cor- 
responding to  the  long  axis  of  the  rib,  and  thus  avoid  the 
intercostal  vessels  and  nerves.  The  wound  should  be 
dressed  antiseptically. 

Excision  of  the  Clavicle. — This  operation  is  performed  for 
necrosis  and  for  morbid  growths.  The  patient  is  placed  on 
the  back,  with  the  shoulders  elevated  from  the  table  and 
head  turned  to  the  opposite  side. 

Contiguous  A?iat07ny. — Its  muscular  and  ligamentous  at- 
tachments must  be  carefully  studied,  for  it  is  by  a  knowl- 
edge of  these  that  the  surgeon  is  enabled  to  raise  the  bone 
from  its  more  important  relations. 

In  front. 

Attachments  of 
Pectoralis  major. 
Sterno-mastoid, 
Trapezium  and  Deltoid. 

Above. 
External  jugular. 

Branches  of  thyroid  axis.      J  ria  •  i    \  Below. 

Subclavian  artery.  \       ^"^  ^'  j  Cephalic  vein. 


Brachial  plexus. 


Behind. 

Internal  mammary  artery — Sternal  half. 
Subclavian  vein  artery,  "  " 

External  jugular. 

Innominate  vein  on  the  right  half. 
Thoracic  duct  on  the  left  half. 
Pleural  cavity. 


EXCISION   OF   CLAVICLE.  213 

Its  intimate  association  to  important  arteries,  veins, 
nerves,  etc.,  surrounds  its  removal  with  great  difficulties 
and  dangerous  complications;  especially,  if  it  be  attempted 
for  a  well-developed  malignant,  or  other  morbid  growth. 
With  the  patient  in  the  position  assumed  for  the  operation, 
the  foregoing  plan  shows  the  important  anatomical  rela- 
tions of  the  clavicle. 

The  whole  or  a  portion  can  be  removed.  If  the  whole  be 
removed,  it  may  be  raised  by  its  scapular  extremity,  or  di- 
vided, and  each  half  taken  away  separately. 

Removal  of  the  E?itire  Clavicle. — Anaesthetize  and  place  the 
patient  in  the  position  just  described;  if  for  necrosis,  make 
an  incision  the  whole  length  of  the  bone  parallel  with  its 
long  axis.  If  necessarj^,  a  short  transverse  incision  is  added; 
expose  the  bone,  divide  the  periosteum,  and  with  the  ele- 
vator enucleate  it  from  the  surrounding  tissues.  It  can  be 
divided  through  the  centre  and  each  half  removed  sepa- 
rately, or  the  acromial  end  can  be  detached  and  the  whole 
raised  by  it.  In  either  instance  the  articular  ends,  and 
their  connective  ligaments  should  be  preserved  if  possible. 

If  the  involucrum  be  weak  and  liable  to  bend  or  break 
after  the  bone  is  removed,  the  shoulder  must  be  held  out- 
ward, backward,  and  upward  by  the  methods  employed  in 
fracture  of  that  bone.  The  indirect  method  of  sequestrot- 
omy  can  be  employed  in  some  instances. 

If  the  operation  be  for  the  removal  of  a  tumor  of  the 
bone,  especially  one  acutely  malignant,  and  involving  any 
considerable  portion  of  the  surrounding  tissues,  it  is  certain 
to  be  an  exceedingly  tedious  and  bloody  one. 

The  smaller  the  size  of  the  tumor  and  the  less  its  vascu- 
larity, the  easier  its  removal.  Make  an  incision  in  the  long 
axis  of  the  bone,  from  the  sternal  to  the  acromial  extremity; 
if  necessary  this  is  crossed  by  a  vertical  one,  extending 
from  the  posterior  border  of  the  sterno-mastoid  to  the  up- 
per third  of  the  pectoralis  major.  Carry  these  incisions  as 
deeply  as  the  nature  of  the  growth  will  permit,  and  refect 
the  flaps  from  off  the  tumor;  separate  the  insertions  of  the 
deltoid  and  trapezius  muscles  on  a  director,  cutting  them 
either  with  a  knife  or  strong  curved  scissors,  being  careful 
to  avoid  the  cephalic  vein  which  lies  at  the  inner  border  of 
the  deltoid.  Divide  the  coraco-  and  acromio-clavicular  liga- 
ments; raise  the  acromial  extremity  of  the  clavicle,  thus 
elevating  the  morbid  growth,  which  should  be  separated 
cautiously  from  the  surrounding  tissues.     The  nearer  the 


214 


OPERATIVE  SURGERY. 


approach  to  the  sternal  extremity,  the  greater  necessity  for 
caution,  since  the  growth  may  be  connected  with  the  im- 
portant structures  there;  finally,  divide  the  sterno-mastoid 
insertion,  the  pectoralis  major,  and  rhomboid  ligament,  and 
carefully  disarticulate  while  the  tumor  is  lifted  upward  and 
inward. 

Either  extremity  may  be  excised  by  making  a  crucial 
incision  corresponding  to  the  portion  to  be  removed  down 
to  the  bone,  exposing  and  dividing  it  with  a  chain  saw,  and 
removing  with  the  same  precautions  as  before  described. 
The  results  of  the  operation  of  complete    excision   have 


Fig.  212. 

been  very  unfortunate,  nearly  all  having  perished  from  ex- 
haustion, due  to  loss  of  blood,  erysipelas,  etc. 

The  entrance  of  air  into  the  veins  is  especially  to  be 
guarded  against,  on  account  of  their  near  proximity  to  the 
chest. 

Excision  of  the  Scapula. — This  bone  is  excised  on  account 
of  gun-shot  injuries,  necrosis,  and  morbid  growths. 

The  whole  bone  may  be  removed,  or  its  body,  angles,  and 
spines  can  be  removed  separately.  Its  contiguous  anatomy 
is  extensive,  but  not  of  the  dangerous  character  found  asso- 
ciated with  the  clavicle.  To  its  spines,  borders,  and  sur- 
faces, are  attached  numerous  and  powerful  muscles. 

At  the  upper  border  are  found  the  supra-scapular  vessels 
gnd  nerves;  the  posterior  scapular  passes  down  its  vertebral 


EXCISION   OF  SCAPULA. 


215 


border;  while  at  the  axillary  border  the  subscapular,  dor- 
salis  scapulse,  and  even  the  axillary  artery  itself,  and  the 
brachial  plexus,  are  in  close  connection  with  it. 

Removal  of  the  Entire  Scapula  (Fig.  212).— Make  an  in- 
cision from  the  top  of  the  acromion  process  along  the  spme 
to  the  posterior  border,  a,  b.  Join  it  by  a  second  from  near 
its  centre  to  the  inferior  angle  of  the  bone,  c,  dj  turn  aside 
the  flaps  thus  formed. 

Separate  the  attachments  of  the  deltoid  and  trapezius; 
disarticulate  the  acromio-clavicular  articulation;  secure  the 
subscapular  artery;  divide  the  ligaments  and  tendons  around 


Fig.  213. 

the  glenoid  cavity;  raise  up  the  coracoid  process  and  care- 
fully sever  its  ligaments  and  muscular  attachments;  raise 
the  bone  upward  and  divide  the  remaining  muscular  at- 
tachments with  a  knife  or  strong  pair  of  scissors,  carefully 
avoiding  the  subscapular  and  posterior  scapular  vessels; 
tie  all  the  bleeding  points;  wash  with  an  antiseptic  solution; 
provide  drainage,  close  the  wound  with  suitable  sutures, 
and  dress  antiseptically. 

Removal  of  the  Body  of  the  Scapula  (Fig.  213).— Make  an 
incision  the  whole  length  of  the  spine,  a,  bj  begin  a  second 


2l6  OPERATIVE   SURGERY. 

at  the  posterior  superior  spine,  and  carry  it  along  the  pos- 
terior border  of  the  bone  to  its  inferior  angle,  c,  dj  dissect 
the  resulting  triangular  flaps  from  their  corresponding 
fossae,  carefully  avoiding  the  supra-scapular  artery  and 
nerve;  saw  through  the  acromion  close  to  the  body,  divide 
the  muscles  attached  to  the  anterior  and  superior  borders; 
raise  the  bone  upwara  and  saw  through  the  anterior  supe- 
rior angle  behind  the  coracoid  process,  turn  the  bone  out- 
ward and  sever  its  posterior  connections  with  the  knife. 

Acromion  Process  aftd  Angles  may  be  separately  removed. 
For  the  former,  make  an  incision  along  its  upper  border, 
which  may  be  curved,  if  necessary:  expose  this  portion  of 


Fig.  214. 

the  bone,  divide  the  muscles  attached  to  It,  and  with  a  pair 
of  bone  forceps  remove  the  desired  amount.  The  acromion 
can  be  removed  by  making  a  curved  or  crucial  incision 
over  it;  expose  its  upper  surface,  divide  the  muscles  con- 
nected therewith,  disarticulate  the  clavicle,  and  remove  with 
a  chain  saw. 

To  remove  an  angle,  make  a  V-shaped  incision  over  it, 
dissect  off  the  flaps,  separate  the  muscles,  and  divide  with 
the  bone  forceps. 

Subperiosteal  Excision  of  the  Scapula  (Fig.  215). — Make 
an  incision  from  the  apex  of  the  acromion  process  along 
the  spine  to  the  posterior  border  of  the  scapula,  a,  b.    Carry 


EXCISION  OF  SCAPULA.  21/ 

a  second  from  the  posterior  superior  angle  along  the  pos- 
terior border,  crossing  the  former,  to  the  inferior  angle,  f,  d. 
Sever  the  muscular  attachments  to  the  acromion  and  spine; 
divide  the  periosteum  at  the  posterior  border  between  the 
attachments  of  the  rhomboideus  major  and  infra-spinatus, 
and  separate  it  from  the  iufra-spinous  fossa.  Separate  the 
inferior  angle  from  its  muscular  attachments.  The  perios- 
teum is  then  raised  from  the  supra-spinous  fossa  in  the 
same  manner;  be  careful  to  not  injure  the  supra-scapular 
vessels,  as  they  pass  in  close  contact  with  the  foramen;  dis- 
connect the  muscles  around  its  borders,  closely  hugging 
the  bone,  raise  it  upward  by  its  inferior  angle,  denude  the 
subscapular  fossa,  leaving  its  periosteum  connected  with  the 
subscapularis;  liberate  the  posterior  border,  allowing  its  car- 
tilaginous border  to  remain — when  present.  Turn  the  bone 
upward  and  forward,  and  remove  the  remaining  periosteum 
from  its  under  surface  to  the  neck  of  the  scapula,  which  is 
divided  with  the  chain  saw.  If  the  disease  will  not  permit 
this,  the  neck  can  be  enucleated,  leaving  the  ligaments  con- 
nected with  the  periosteum.  If  the  bone  be  retnaved  for  a 
malignant  or  other  morbid  growth,  make  an  incision  from 
the  posterior  superior  angle  to  the  lower  border  of  the 
tumor,  carrying  it  downward,  forward,  and  inward,  with 
the  convexity  posteriorly.  A  second,  beginning  five  inches 
or  so  in  front  of  the  preceding,  carried  downward  and  back- 
ward, crossing  the  other  at  or  near  its  middle,  and  termi- 
nating at  the  lower  border  of  the  growth.  The  flaps  are 
then  reflected  from  the  tumor,  and  the  muscular  attach- 
ments of  the  spine  separated,  and  the  acromion  process 
sawn  through  behind  the  clavicle;  expose  the  superior  and 
posterior  borders,  and  free  them  of  their  attachments;  raise 
the  bone  upward  and  forward  by  its  posterior  border,  and 
sever  the  serratus  magnus  from  it;  free  the  axillary  border, 
and  divide  the  neck  with  a  saw,  if  practicable.  When  neces- 
sary, complete  the  entire  removal  by  disarticulation. 

It  is  not  possible  to  lay  down  absolutely  practical  rules  to 
govern  the  number,  extent,  or  direction  of  the  incisions;  all 
this  must  depend  on  the  size  and  situation  of  the  growth, 
together  with  the  amount  of  bone  to  be  removed,  and  the 
ease  and  safety  with  which  it  can  be  done.  After  the  re- 
moval, arrest  hemorrhage,  provide  good  drainage,  unite  the 
cut  surfaces,  and  dress  antiseptically. 

The  results  of  the  operation  are  flattering:  27  per  cent 
died  after  complete  removal  for  injuries,  and  19  per  cent 


218 


OPERATIVE  SURGERY. 


when  due  to  disease.  The  mortality  was  26  per  cent  in 
partial  excisions  for  disease,  and  about  20  per  cent  when 
done  for  injury. 

Excision  of  the  Humerus. — This  can  be  removed  entirely 
or  in  part. 

The  Important  Associated  Anatomy. — The  insertions  of  the 
muscles  acting  upon  the  upper  end  of  the  bone,  course  of 
the  superior  profunda,  and  circumflex  arteries,  of  the  cir- 


FlG.  315. 


cumflex,  musculo-spiral  and  ulnar  nerves;  points  of  inser- 
tion of  the  ligaments  of  the  joints,  together  with  the  con- 
nections of  the  flexors  and  extensors,  must  be  carefully  con- 
sidered before  attempting  the  operation.  This  operation 
has  been  done  for  the  relief  of  old  dislocations,  caries,  ne- 
crosis, gun-shot  injuries,  arthritis,  malignant  disease,  etc. 
Excision  of  the  Upper  End. — Place  the  patient  upon  the 


EXCISION  OF  HUMERUS. 


219 


back,  with  the  shoulders  raised;  make  an  incision  from 
the  anterior  border  of  the  acromion  process,  close  to  the 
articulation  with  the  clavicle,  downward,  about  four  inches, 
in  the  line  of  the  bicipital  groove  (Fig.  215).  The  bone 
at  this  region  is  quite  superficial;  liberate  the  long  head  of 
the  biceps  tendon  from  the  groove,  by  carrying  the  point 
of  the  knife  upward  in  it  at  the  outer  side,  through  the 
capsule  to  the  acromion,  and  raise  it  out  of  the  groove  (Fig. 
216);  rotate  the  arm  outward  and  divide  the  subscapularis 
tendon  and  inner  portion  of  the  cap- 
sule; tken  inward,  cutting  the  ex- 
ternal rotators  and  posterior  por- 
tion of  the  capsule  (Fig.  217);  force 
the  head  of  the  bone,  through  the 
opening,  seize  it  with  a  strong  pair 
of  forceps,  divide  the  inferior  por- 
tion of  the  capsule  and  remove  ih?. 
head  of  the  bone  with  a  chain  or 
a  small  straight  saw  (Fig.  218). 

Subperiosteal  Excision  of  Head  of 
Hiwierus.  —  Expose  the  bicipital 
groove  and  split  up  the  capsular 
ligament  as  in  the  preceding  opera- 
tion. Divide  and  raise  the  perios- 
teum from  the  inner  border  of  the 
bicipital  groove,  passing  inward 
and  separating  it  along  with  the 
subscapularis  and  the  fibrous  cap- 
sule from  the  lesser  tuberosity. 
Rotate  the  humerus  outward  and 
complete  the  separation  to  the  re- 
quired extent  with  the  elevator  and  knife;  rotate  the  arm 
inwards,  displace  the  tendon  of  the  biceps  to  the  inner 
side  of  the  head  and  separate  the  periosteum  in  connection 
with  the  capsule  and  the  insertions  of  the  external  rotators, 
being  very  careful  not  to  sever  its  connection  with  the 
bone  below.  To  force  the  head  through  the  external  open- 
ing is  practically  impossible  without  destroying  the  perios- 
teal connections;  it  is  necessary,  therefore,  to  divide  it  with 
a  chain  or  narrow-bladed  saw.  Partial  removal  of  the 
upper  extremity  is  often  necessary  on  account  of  disease 
or  injury. 

The  variety  and  extent  of  the  incisions  to  reach  the  part 
must  be  governed  by  the  amount  of  the  disease. 


Fig.  216. 


220 


OPERATIVE   SURGERY. 


The  vertical,  V-,  and  U-shaped  ones  are  selected  as  best 
suits  the  exigencies  of  the  case. 

Excisio7i  of  the  Glenoid  Cavity. — This  operation  is  only- 
applicable  to  those  conditions  of  injury  or  disease  that  are 
limited  to  the  glenoid  articular  surface  of  the  scapula.  If 
a  penetrating  wound  has  ensued,  its  course  should  be  fol- 
lowed to  reach  the  bone;  if  not,  then  a  curved  insertion  is 
made  around  the  posterior  border  of  the  acromion  which 


Fig.  217. 

divides  the  fibres  of  the  deltoid,  and  exposes  the  pos- 
terior and  upper  surface  of  the  joint.  A  second  incision 
is  then  made,  commencing  at  the  centre  of  this  one,  at  the 
upper  margin  of  the  glenoid  cavity,  and,  passing  down- 
ward through  the  capsule,  upon  the  centre  of  the  greater 
tuberosity,  between  the  supra  and  infra-spinatus  tendons 
through  the  deltoid  in  the  direction  of  its  fibres  (Fig.  219). 
Open  the  wound  widely  by  means  of  retractors  and  divide 


'  EXCISION  OF  HUMERUS. 


221 


the  tendons  of  the  biceps  at  its  insertion;  separate  the 
periosteum  around  the  neck  of  the  scapula  if  possible, 
leaving  the  attachments  of  the  capsular  ligament.  Cut 
away  the  bone  with  a  chain  saw.  The  wound  is  then 
dressed  as  usual  in  such  cases. 

Excision  of  the  Shaft. — Unless  great  caution  be  obser\^ed, 
the  musculo-spiral  nerve  and  the  superior  profunda  artery 
will  be  injured  in  their  course  along  the  musculo-spiral 


Fig.  218. 


Fig.  aig. 


groove.  The  circumflex  nerves  and  vessels  also,  if  tht 
incision  be  extended  (Fig.  220)  upward  too  far.  The  up- 
per portion  of  the  shaft  is  easily  exposed  by  making  an  in- 
cision of  sufficient  length  through  the  outer  surface  of  the 
deltoid,  commencing  at  its  lower  third  and  dividing  it  con- 
tinuously upward,  to  avoid  the  circumflex  nerve  and  artery; 
the  bone  is  then  denuded  of  its  periosteum,  or  the  morbid 


222 


OPERATIVE   SURGERY 


growth  circumscribed  and  removed.  If  it  be  the  lower  por- 
tion of  the  shaft,  make  the  incision  along  the  outer  border 
of  the  brachialis  anticus,  carefully  avoiding  the  musculo- 
spiral  nerves;  expose  the  bone  and  remove  it  as  before. 

The  Lower  Extre7nity  of  the  Humerus. — The  relation  of  the 
ulnar  nerve  to  the  internal  condyle  (Fig.  221)  and  of  the 
brachial  artery  to  its  anterior  surface,  must  not  be  forgot- 
ten; make  an  incision  on  the  posterior  and  external  surface 


Fig.  220. 


of  sufficient  length  to  well  expose  the  bone;  elevate  the 
periosteum  and  divide  with  a  chain  saw;  pull  the  fragment 
downward  and  disarticulate. 

If  it  be  required  to  remove  the  whole  humerus,  make  in- 
cisions as  if  to  remove  the  upper  and  lower  portions,  ob- 
serving the  same  precautions  relative  to  the  anatomy  of 
these  parts.  The  musculo-spiral  nerve  in  this  is  to  be  most 
cautiously  guarded. 


EXCISION  OF  ELBOW-JOINT. 


223 


In  all  the  preceding  operations,  substantially  the  same 
after-treatment  is  required:  stop  the  hemorrhage,  irrigate 
with  an  antiseptic  solution,  provide  drainage,  close  the 
lips  of  the  wound,  and  surround  with  antiseptic  dressing. 
Place  the  limb  upon  a  splint  affording  an  easy  support  at 
the  proper  angle.     Extension  is  often  necessary  to  main- 


trnS.  Tlmgut^ 


<iniiiiiMi  I  jj 


tttBuoBiiBrsimi 


frf^ffB 


Aru&lOEft 


0asi£Busi-Mliuab 


Fig. 


tain  the  limb  at  a  suitable  length  during  the  healing  pro- 
cess. 

The  results  depend  much  upon  the  nature  of  the  injury 
and  the  period  of  the  operation.  For  gunshot  wounds  of 
the  bone  requiring  excision,  about  35  per  cent  perish. 
The  rate  of  mortality  being  increased  when  the  inflamma- 
tory stage  exists  at  the  time  of  operation. 

Excision  of  the  Elbo^v  Joint  (Hueter). — With  the  forearm 
extended  make  a  straight  incision  about  an  inch  in  length 


224 


OPERATIVE  SURGERY. 


1 


t  1 

\ 
I 

l\ 

(  \ 
I    i 


■I 


down  upon  the  tip  of  the  internal  condyle,  carefully  avoid- 
ing the  ulnar  nerve  (Fig.  221).  Through  this  opening  sep- 
arate the  muscular  and  ligamentous  attachments  to  the  con- 
dyle; make  a  second  longitudinal  incision  from  three  to  four 
inches  in  length  down  to  the  head  of  the  radius  (Fig.  222). 
Draw  aside  the  soft  parts  and  cut  the  external  lateral  and 
orbicular  ligaments  (Fig.  223).  Expose  the  head  of  the 
radius  and  cut  off  with  a  saw  or  bone  forceps.  Separate 
the  capsular  ligament  from  its  attachments  on  the  anterior 
and  posterior  surfaces  of  the  humerus,  force  the  bone  out 
of  the  external  wound;  this  movement  admits  of  its  divi- 
sion, and  at  the  same  time  raises  the  ulnar 
nerve  from  its  bed  away  from  the  bone. 
Saw  off  the  lower  end  of  the  humerus,  care- 
fully expose  and  remove  the  olecranon. 

Subperiosteal  Excision  of  Elbow  (Lan- 
genbeck). — Make  a  longitudinal  incision 
down  to  the  bone,  three  to  four  inches 
in  length,  a  little  to  the  inner  side  of  the 
olecranon  (Fig.  224),  about  two  thirds  of  its 
length  being  below  the  tip  of  the  olecranon. 
Relieve  that  portion  of  the  olecranon  and 
ulna  at  the  inner  side  of  the  incision 
of  the  periosteum.  Separate  by  short 
parallel  incisions  the  attachments  of  the 
inner  half  of  the  triceps  tendon.  Push 
the  tissues  at  the  internal  condyle,  to- 
gether with  the  ulnar  nerve  inward  to- 
wards the  tip  of  the  condyle,  and  elevate 
the  periosteum  from  the  inner  condyle 
sufficiently  to  separate  the  internal  lateral  ligaments  and 
muscles  from  the  bone,  leaving  them  connected  with  the 
periosteum.  The  liberated  tissues  are  now  permitted  to 
return  to  their  former  position,  and  the  outer  portion  of 
the  tendon  is  drawn  outward  and  disconnected  from  the 
process  by  short  transverse  incisions,  closely  hugging  the 
bone  and  allowing  it  to  remain  continuous,  with  the 
periosteum;  which  is  reflected  from  the  inner  surface 
of  the  olecranon  and  shaft  of  the  ulnar;  expose  the  ex- 
ternal condyle  by  separating  the  capsular  ligament  at  its 
attachment,  above  the  trochlear  and  capitillium,  the  tis- 
sues, including  the  detached  periosteum  and  tendons  of 
the  biceps,  are  separated  well  from  the  bone  by  retractors. 
Flex  the  forearm  and  force  the  extremities   of  the  bones 


Fig. 


EXCISION   OF   ELBOW-JOINT. 


22$ 


through  the  openings;  saw  off  the  head  of  the  radius, 
lower  end  of  the  humerus  and  finally  the  olecranon  pro- 
cess. It  is  important  to  remember  that  in  all  cases  of  ex- 
cision about  the  elbow  joint,  to  respect  the  insertions  of  im- 
portant muscles,  as  the  insertion  of  the  brachialis  anticus, 
biceps,  triceps,  etc.  To  unnecessarily  destroy  the  power  of 
one  of  these,  is  to  be  guilty  of 
an  unpardonable  oversight. 
Variously  formed  incisions, 
other  than  the  longitudinal, 
have  been  employed:  as  the  H, 
with  the  horizontal  portions 
corresponding  to  the  articula- 
tion; the  T,  with  the  horizon- 
tal on  a  line  with  the  condyle; 
U-shaped  or  semilunar,  with 
the  convexity  downward. 

Excision  of  the  Joint  by  the 
I — Shaped  Incision  (Liston's, 
Fig.  225). — Flex  the  elbow  to 
an  obtuse  angle,  the  operator 
facing  its  posterior  surface 
(Fig.  226),  open  the  capsule 
between  the  olecranon  and  in- 
ternal condyle  by  a  longitu- 
dinal incision  about  four  inches 
in  length  along  the  inner 
border  of  the  olecranon,  dis- 
sect and  draw  the  soft  parts 
over  the  internal  condyle  with 
the  thumb  (Fig.  226),  increas- 
ing the  flexion  gradually  till 
the  condyle  is  fully  exposed, 
divide  the  internal  lateral  liga- 
ment, extend  the  arm  and  carry 
a  transverse  incision  from  the 
point  of    articulation    of    the  ^"^-  "3- 

radius  with  the  humerus  directly  across  to  the  centre  of  i' 
the  former  incision. 

The  periosteum  on  the  inner  surface  of  the  olecranon 
and  ulna  is  raised  and  left  connected  with  the  tendon  of 
the  triceps,  which  is  carefully  separated  from  the  bone. 
Open  the  flaps  wide  and  divide  the  external  lateral  liga- 
ment, flex   the   forearm,  when   the   articular  surfaces  will 


226 


OPERATIVE  SURGERY. 


separate.  Seize  and  saw  off  the  lower  extremity  of  the 
humerus  and  the  olecranon  process,  finally  the  head  of  the 
radius.     Dress  as  in  the  preceding  instance. 

Excision  of  the  Elboiv  Joint  has  been  done  with  such  suc- 
cess that  its  rank  is  thoroughly  established.  Although 
when  due  to  injury  the  rate  of  mortality  is  about  25  per  cent, 
when  due  to  disease  it  is  less  than  11  per  cent.  Partial 
excisions  are  followed  by  better  results,  so  far  as  motion 
is  concerned,  than  complete  ones. 

It  would  appear  that  the  saving  of  the  synovial  mem- 


FiG.  224. 


Fig.  225. 


brane  exerts  a  more  conservative  influence  upon  the  useful- 
ness of  the  joint  than  the  saving  of  bone;  provided,  of  course, 
that  the  bony  insertions  of  the  muscles  acting  directly  upon 
the  joint  be  respected.  The  amount  of  bone  removed  will 
determine  the  usefulness  of  the  joint.  If  too  little,  the 
moTement  will  be  limited  and  insufficient;  if  too  great,  it 
will  dangle,  and  be  of  little  use  except  for  carrying  pur- 
poses. If  the  operation  be  for  traumatism,  remove  the 
fragment;  if  for  disease,  remove  only  the  diseased  portion, 


EXCISION  OF  ULNA. 


227 


and  in  all,  the  wounds  should  be  washed  with  a  suitable 
antiseptic  solution,  closed  with  proper  drainage,  dressed 
antiseptically,  and  kept  extended  till  repair  is  begun ; 
when  it  should  from  time  to  time  be  placed  at  various 
angles  for  a  day  or  so.     By  this  course  the  newly  formed 


Fig.  236. 


tissue  will  conform  more  readily  to  the  various  positions  of 
the  joint  thereafter. 

Excision  of  the  Ulna. — An  incision  is  made  along  the  pos- 
terior surface  of  sufficient  length  to  expose  the  diseased 
portion,  the  periosteum  pushed  aside,  and  section  made  at 
the  requisite  point  and  the  bone  removed. 


228 


OPERATIVE  SURGERY. 


If  it  be  a  partial  excision  of  the  upper  extremity,  ex- 
pose that  portion  by  incision  in  the  same  line,  remove  the 
periosteum,  leaving,  if  possible,  the  attachments  of  the 
brachalis  anticus  and  triceps.  Respect  the  ulnar  nerve,  at 
the  inner  condyle. 

Excisio7i  of  the  Radius. — Make  an  incision,  extending  from 
the  styloid  process,  along  the  outer  side  of  the  anterior 
surface  of  the  forearm  to  the  radio-humeral  articulation, 
through  the  integument  and  fascia.  Seek  the  inner  border 
of  the  supinator  longus,  pass  upward  separating  it  from  the 
flexor  longus  pollicis  and  going  down  to  the  bone,  divide  the 


Fig.  227. 


supinator  brevis,  also  the  periosteum  in  the  long  axis  and 
separate  it;  divide  the  bone  in  the  centre,  and  remove  each 
portion  separately.  The  insertion  of  the  biceps  and  pronator 
radii  teres  should  be  carefully  preserved.  If  either  ex- 
tremity be  exsected,  expose  the  bone  through  an  incision 
made  in  the  same  line  as  the  preceding;  the  periosteum 
is  reflected  with  equal  caution,  and  the  bone  removed. 

Excision  of  the  Wi'ist  Joint. — This  joint  properly  consists 
of  the  radius,  articulated  with  the  outer  two  of  the  first  row 
of  carpal  bones.  In  cases  where  excision  is  necessary,  it  is 
not  usual  to  find  the  disease  or  injury  limited  entirely  to 
these  structures.    It  therefore  becomes  necessary  to  remove 


EXCISION   OF  WRIST.  229 

all  bony  structures  involved,  even  though  it  embraces  the 
two  rows  of  carpal  bones  and  the  contiguous  extremities  of 
the  metacarpal.  The  intimate  relation  existing  between 
the  carpal  bones  and  the  continuity  of  their  synovia  sur- 
roundings, renders  them  especially  liable  to  extending  dis- 
ease as  well  as  inflammatory  processes  (Fig.  227).  They  are 
intimately  bound  together  by  strong  ligaments  admitting  of 
but  limited  movement  between  their  surfaces  (Figs.  228  and 
229).     Since  these  bones  are  environed  by  the  tendons  of 


Fig.  228. 

important  muscles,  the  sheaths  of  which  should  be  scrupu- 
lously preserved  along  with  themselves,  it  surrounds  this 
operation  with  difficult  and  tedious  details. 

All  diseased  or  detached  bone  should  be  removed.  If  a 
portion  of  a  carpal  bone  be  diseased,  it  is  better  that  the 
whole  be  removed.  The  insertions  of  all  muscles  acting  on 
the  carpus  should  be  preserved,  if  possible. 

No  tendon  is  to  be  divided,  except  it  be  an  unsurmount- 
able  obstacle  to  the  incision  necessary  to  the  removal  of  the 
bones.  The  radial  and  ulnar  arteries  and  the  branches 
associated  with  the  carpus  should  be  cautiously  avoided. 

Complete  Exeision  of  the  JFri'st  (Langenbeck). — Place  the 
forearm  and  hand  of  the  patient  with  the  palm  downward 


230  OPERATIVE   SURGERY. 

on  a  table  of  convenient  height  for  the  operator  and  his 
assistant.  An  incision  is  then  made  through  the  integu- 
ment, beginning  at  the  middle  of  the  metacarpal  bone  of 
the  index  finger  at  its  ulna  border,  and  extending  lon- 
gitudinally to  three-fourths  of  an  inch  above  the  lower 
extremity  of  the  radius,  at  its  middle  (Fig.  230).  The 
deeper  course  of  the  incision  passes  to  the  radial  side  of 
the  extensor  indicis  without  opening  its  sheath,  upward, 
either  over  the  tendon  of  the  extensor  carpi  radialis  bre- 
vior,  or  to  the  inner  side  of  its  insertion,  depending  on  the 
degree  of  adduction  of  the  hand;  then,  if  the  tendons 
going  to  the  index  finger  be  pushed   to  the   ulnar  side, 


Fig.  229. 

upward  to  the  point  of  termination  between  the  tendons 
of  the  extensor  secundi  internodii  pollicis  and  the  extensor 
indicis  (Fig.  230),  dividing  the  lower  portion  of  the  posterior 
annular  ligament.  Draw  the  tissues  apart  with  suitable 
retractors  and  separate  the  fibrous  sheaths  of  the  extensors 
of  the  carpus  situated  on  the  posterior  surface  of  the  radius 
with  a  periosteal  elevator,  also,  the  insertion  of  the  supinator 
longus,  annular  ligament,  periosteum,  and  capsular  liga- 
ment are  then  disconnected  and  drawn  inward;  the  ten- 
dons, ligaments,  and  periosteum  on  the  posterior  surface  of 
the  ulna  are  separated  in  the  same  manner  and  drawn  out- 


EXCISION  OF  WRIST.  23I 

ward;  open  well  the  radio-carpal  joint,  flex  the  carpus 
and  expose  the  articular  surfaces,  and  separate  the  bones 
of  the  first  row  from  their  connection  with  each  other, 
leaving  the  periosteum  if  possible.  Liberate  the  scaphoid 
from  the  trapezium  and  trapezoid,  the  semilunar  from  the 


Fig.  230. 

OS  magnum,  and  the  cuneiform  from  the  unciform;  lift  them 
out,  leaving,  if  possible,  their  periosteum  and  the  trapezium. 
The  bones  of  the  anterior  row  are  taken  out  after  severing 
the  connections  between  the  trapezium  and  trapezoid  and 
the  heads  of  the  metacarpal  bones.     The  extremities  of  the 


232 


OPERATIVE   SURGERY. 


radius  and  ulnar  can  now  be  forced  through  the  wound, 
carefully  stripped  and  sawn  off,  carefully  avoiding  the 
radial  and  ulnar  vessels.  The  resulting  wound  is  treated 
by  antiseptic  measures,  attended  when  possible  with  exten- 
sion. Continuous  extension  from  the  fingers  should  be 
early  and  constantly  employed  during  the  after  treatment. 
Excision  of  the  Lower  Extremities  of  the  Bones  of  the  Fore- 
arm (Bourgary). — Make  an  incision  along  the  inner  side 
of  the  ulnar,  from  just  below  the  apex  of  the  styloid  pro- 
cess two  inches  along  the  inner  border  (Fig.  231).  Divide 
the  periosteum  at  the  interspace  be- 
tween the  extensor  and  flexor  carpi 
ulnaris  in  the  same  line,  and  reflect 
it  from  the  bone  inward  to  the  inter- 
osseous membrane.  The  denuded 
extremity  of  the  ulna  is  then  re- 
moved, and  a  second  longitudinal 
incision  is  made  along  the  outer  side 
of  the  radius  from  just  below  the 
apex  of  the  styloid  process  two  or 
three  inches  upward,  divide  the 
periosteum  through  the  same  inci- 
sion, separate  the  attachment  of 
the  supinator  longus,  and  raise  the 
periosteum  on  the  dorsal  surface 
along  with  the  sheath  of  the  exten- 
sor tendons. 

The  periosteum  is  then  elevated 
from  the  like  portion  of  the  palmar 
surface  around  to  the  interosseous 
membrane.  Protect  the  perios- 
teum and  soft  parts  while  the  bone 
is  being  sawn  through. 

There  are  other  i?icisions  intended 
to  meet  the  indication,  i.  (Lis- 
ter). Beginning  on  the  dorsal 
aspect  of  the  radius,  opposite  the 
styloid  process.  Carry  it  towards 
Fig.  231.  the  inner  side   of   the    metacarpal 

articulation  of  the  thumb  parallel  with  the  secundi  in- 
ternodii  pollicis  (Fig.  232).  When  at  the  radial  border 
of  the  second  metacarpal  bone,  carry  it  along  one  half 
the  length  of  that  bone;  separate  the  soft  parts  on  the 
radial  side,  divide  the  tendon  of  the  extensor  carpi  radi- 


EXCISION  OF  CARPUS. 


233 


alls  longior  at  its  insertion,  raise  it  along  with  the  brevior 
and  secundi  internodii  pollicis,  open  the  wound  well  and  dis 
connect  the  trapezium  from  the  remaining  bones,  which  are 
then  taken  away.     Extend  the  carpus  and  separate  the  soft 
parts  on  the  dorsum  at  the  ulnar  side  of  the  incision. 

Make  a  second  incision  along  the  anterior  and  internal 
border  of  the  forearm  inside  the  flexor  carpi  ulnaris,  be- 
ginning about  two  inches  above  the  styloid  process  and 
extending  to  the  middle  of  the  metacarpal  bone  of  the  lit- 


FlG.  332. 


tie  finger.  Expose  the  dorsum  of  the  ulna,  divide  the  ten- 
don of  the  extensor  carpi  ulnaris  at  its  insertion,  separate  it 
from  the  groove  in  the  ulna,  raise  the  extensors  of  the 
fingers  from  the  carpus,  leaving  their  attachments  to  the 
radius  intact;  expose  the  entire  surface  of  the  ulna,  hugging 
the  bone  closely;  separate  the  pisiform  bone  with  the  flexor 
carpi  ulnaris;  flex  the  hand  and  separate  the  flexor  tendons 
in  the  same  cautious  manner;  divide  the  remaining  liga- 
ments connecting  the  bones  of  the  forearm  with  the  carpus. 


234  OPERATIVE   SURGERY. 

Separate  the  process  of  the  unciform  bone,  also  the 
carpus  from  the  metacarpus  with  cutting  forceps;  expose 
the  extremities  of  the  radius  and  ulna  through  the  ulnar 
incision,  remove  with  saw  or  forceps  the  diseased  portions, 
carefully  avoiding  the  grooves  for  the  passage  of  the  ten- 
dons; remove  the  trapezium  without  injury  to  the  tendon 
of  the  flexor  carpi  ulnaris.  All  articular  surfaces  of  bones 
— metacarpal  bones,  pisiform  and  between  lower  extremities 
of  radius  and  ulna — should  be  removed,  as  well  as  all  dis- 
eased portions  of  bone.  Many  other  incisions  are  made 
to  affect  the  removal;  but  only  such  as  admit  of  it  being 
done  through  longitudinal  incisions  are  advisable,  since 
transverse  incisions  sacrifice  the  tendons  which  impart  use- 
fulness to  the  remaining  portion. 

All  hemorrhage  having  ceased,  the  wound  should  be 
closed,  allowing  the  most  dependent  incision  to  remain  open 
for  drainage  and  the  introduction  of  supporting  dressings. 
Envelope  the  limb  in  antiseptic  dressings,  causing  the  whole 
to  be  properly  supported  by  a  splint.  The  subsequent 
treatment  consists  in  cleanliness,  extension,  and  passive 
motion. 

Results. — Seven  per  cent  die  after  excision  for  disease  ; 
15  per  cent  for  gunshot.  In  about  2)Z  pe^''  cent  of  those  who 
recover,  the  operation  is  worthless.  In  about  11  per  cent 
entirely  satisfactory;  in  the  remainder,  useful.  The  prog- 
nosis for  usefulness  is  better  when  due  to  injury  than  to 
disease. 

Excision  of  the  Metacarpo-phalangeal  Joints. — This  can  read- 
ily be  done  by  making  an  incision  about  one  and  one  half 
inches  in  length  along  the  dorsum  of  the  bones  composing 
the  joint  at  one  side  of  the  extensor  tendons.  The  tissues 
in  contact  with  the  bone  are  carefully  raised  and  turned 
aside,  the  joint  exposed,  and  the  requisite  amount  of  bone 
removed  by  the  chain-saw  or  cutting  forceps. 

The  phalangeal  articulations  may  be  approached  either 
through  a  longitudinal  incision  made  along  the  side  of  the 
joint,  or  by  a  curved  one  corresponding  to  the  outer  surface 
with  the  convexity  downward.  In  either  instance  raise 
the  tissues  by  carefully  clinging  to  the  bones,  which  when 
properly  exposed  can  be  caused  to  protrude  through  the 
incision  by  lateral  flexion  and  their  extremities  be  re- 
moved. 

The  dressing  consists  in  placing  them  in  an  immovable 
position     properly    protected    by  an    antiseptic    method, 


EXCISION   OF  JOINTS   OF  FOOT.  235 

and  when  repair  begins  passive  motion  must  be  begun 
and  continued  until  the  recovery  is  complete. 

Excision  of  the  Joints  of  the  Lower  Extrefnities. — The  pha- 
langeal joints  of  the  tarsus  are  removed  in  a  similar  man- 
ner to  those  of  the  upper  extremity. 

The  Metatarso-phalangeal  Joints  3.r&  removed  through  lon- 
gitudinal incisions  made  on  the  dorsal  surface  of  the 
bones  constituting  the  joints  at  either  side  of  the  extensor 
tendon,  which  is  pushed  aside  along  with  the  remaining  sur- 
rounding soft  parts,  the  bones  exposed,  and  their  extremi- 
ties severed  by  the  chain-saw  or  bone-forceps.  The  re- 
moval of  the  metatarso-phalangeal  articulation  of  the 
great  toe  can  be  and  often  is  done  differently.  Make  a 
curved  incision  with  the  convexity  downward,  at  the  inner 
side  of  the  joint,  its  centre  corresponding  to  the  joint 
centre,  of  sufficient  length  to  freely  expose   the  bones  to 


Fig.  233. 
(■ 

be  removed  (Fig.  233).  Dissect  the  soft  parts  from 
around  the  bones,  carefully  pushing  aside  the  tendons; 
expose  and  remove  the  necessary  amount  of  bone  with 
chain-saw  or  forceps.  If  the  operation  be  done  for  the 
correction  of  the  deformity  caused  by  prominence  of  the 
head  of  the  metatarsal  bone,  enough  bone  is  removed 
from  its  extremity  to  permit  the  easy  return  of  the  dis- 
placed toe  to  its  natural  position;  where  it  is  to  be  retained 
quietly  till  repair  is  well  advanced,  when  passive  motion 
is  commenced. 

The  Metatarso-ta7-sal  Joints  can  be  exsected  by  raising  a 
semilunar  flap  over  their  dorsal  surface;  avoiding  division 
of  the  extensor  tendons,  which  are  raised  and  pushed  aside, 
while  the  dorsal  ligaments  connecting  the  bones  are  divid- 
ed and   the  joint  cavity  exposed  by  forced   flexion,  after 


236  OPERATIVE  SURGERY. 

Which  the  extremities  of  the  bones  of  the  distal  roW  Can  be 
divided  with  a  saw  or  bone  forceps.  The  corresponding 
extremities  of  the  tarsal  bones  can  be  treated  likewise. 

Tarsal  Joints. — When  separate  tarsal  joints  become  in- 
volved by  disease  or  traumatic  violence,  they  can  be  re- 
moved by  making  an  incision  over  the  injured  or  diseased 
portions,  often  following  in  the  line  of  the  course  of  the 
violence,  or  in  the  tracks  of  sinuses  leading  therefrom. 

This  treatment  is,  however,  better  adapted  to  those  joints 
having  a  limited  synovial  membrane,  than  to  those  where 
that  membrane  extends  between  several  contiguous  bone 
surfaces;  in  the  latter  case  it  is  often  better  to  remove  the 
bones  entire  by  aid  of  the  chisel,  saw,  or  gouge.  In  either 
instance  curved  incisions  are  preferrible,  provided  they  do 
not  divide  important  tendons  and  vessels. 

Excision  of  the  Ankle  Joint. — This  is  a  hinge-joint,  having 


Fig.  234. 

no  lateral  movement,  except  the  foot  be  well  extended,  and 
then  it  is  very  limited.  The  indications  calling  for  the 
operation  are  numerous,  and  should  be  well  considered  be- 
fore it  is  attempted.  As  in  all  excisions  those  procedures 
which  best  preserve  the  tendons,  vessels,  nerves,  and  perios- 
teum are  to  be  adhered  to,  consequently  those  of  a  longi- 
tudinal character  are  best  employed. 

Operation,  Subperiosteal  (Langenbeck). — Make  an  incision 
down  to  the  bone  (Fig.  234),  about  three  inches  in  length 
along  the  posterior  border  of  the  lower  extremity  of  the 
fibula,  carrying  it  forward  in  a  hooked  shape  around  the 
lower  end  and  upward  along  its  anterior  border  about  an 
inch.  The  periosteum  is  reflected  from  the  bone  along 
with  the  tissues  in  contact  with  it,  thereby  exposing  the 
lower  extremity  of  the  fibula  without  opening  tke  tendi- 


EXCISION   OF  ANKLE. 


237 


nous  grooves  of  the  peronei  muscles  (Fig.  235).  The  fibula 
is  then  divided  at  the  upper  end  of  the  cut  with  a  narrow- 
saw,  pulled  outward,  and  the  ligamentous  attachments  along 
its  inner  border  and  surfaces  disconnected  (Fig.  236),  and 
the  bone  removed.  An  incision  is  then  made  about  an  inch 
and  a  half  in  length  down  to  the  bone,  around  the  lower- 
end  of  the  inner  malleolis  (Fig.  237).     A  second  and  ver- 


—  LmkISZ. 


Fig.  235. 


tical  one  is  next  made  about  two  inches  in  length,  down  to 
the  bone  through  the  centre  of  tibia,  connecting  with  the 
semicircular  one  first  made.  The  triangular  flaps  are  turned 
aside,  including  the  periosteum,  with  the  elevator,  using 
care  to  raise  the  sheath  of  all  tendons  from  their  grooves 
(Fig.  238),  push  them  aside,  divide  the  tibia  at  the  upper 
end  of  the  cut  with  a  chain  saw;  pull  it  outward  with  the 
forceps,  free  it  from  the  interosseous  membrane,  as  in  the 
preceding  instance,  and  remove  the  bone.     If  it  be  neces- 


238 


OPERATIVE  SURGERY. 


sary  to  remove  the  articular  surface  of  the  astragalus,  it  can 
be  done  through  either  incision;  the  better,  however, 
through  the  internal  one,  on  account  of  the  greater  amount 
of  room.     Results:  About  13  per  cent  die  from  excision  of 


Fig.  236, 


this  joint;  the  rule  of  mortality  being  about  50  per  cent 
greater  from  disease  than  from  injury. 

The  prognosis  for  life  is  most  favorable  between  one  and 
fifteen  years  of  age.  Most  unfavorable  between  thirty  and 
forty.  A  large  proportion  of  the  recoveries  from  this  results 


Fig.  237. 

in  a  more  or  less  useful  limb;  about  9  per  cent  being  worth- 
less. 

The  treatment  consists  in  the  immovable  dressing  of  the 
joint,  after  the  usual  washing  and  drainage  has  been  es- 
tablished. 


EXCISION  OF  KNEE. 


239 


If  it  be  desired  to  remove,  by  section  or  otherwise,  por- 
tions of  either  of  the  bones  of  the  leg,  the  external  incision 
is  governed,  as  to  its  location  and  extent,  by  the  situation 
and  degree  of  the  injury  or  disease.  The  bone  should, 
however,  be  reached  by  the  shortest  course,  which  should 
be  carried  behveen  the  individual  muscles,  rather  than 
through  their  structures.  After  its  removal,  which  should 
always  be  subperiosteal,  the  limb  must  be  so  confined  as  to 
permit  the  new  structure,  when  completed,  to  fulfil  the  re- 
quirements of  its  predecessor. 

Excision  of  the  Knee  Joint. — This  joint  can  be  excised  with 


f.  JtftfiL 


fJh>  Stx.  hal.    .. 
pfl.  Eh^  post., 


ti^,  UhhMSOlkiA' 


Fig.  238. 

comparative  safety  to  the  patient,  and  with  a  fair  prospect 
of  recovery  with  a  useful  limb.  As  in  the  preceding,  the 
nature  of  the  cause  demanding  the  operation  exercises  a 
marked  influence  on  the  result. 

Resjilts :  The  mortality,  when  due  to  disease,  is  about  30 
percent;  when  dependent  upon  injury,  about  40  per  cent. 

If  it  be  a  gunshot  injury,  the  mortality  is  increased  to  75 
per  cent.  The  age  of  the  patient  is  a  consideration  not  to 
be  underestimated;  being  best  from  five  to  ten  years,  when 
due  to  injury  or  disease;  15  to  20  per  cent  when  done  for 
gunshot  wounds.  Complete  excision  gives  a  higher  rate 
than  partial,  when  due  to  disease  or  injury.  The  removal 
of  about  three  inches  insures  the  best  prognosis  for  life. 


240 


OPERATIVfi  StJRGERV. 


A  less  or  greater  amount  increases  the  rate  per  cent.  The 
removal  of  the  patella,  when  not  diseased,  increases  the  rate 
of  mortality  slightl5^  The  usefulness  of  the  limb  after  the 
operation  can  be  briefly  summed  up  as  follows: 

When  due  to  disease,  14  per  cent  were  perfect,  42  were 
useful,  and  the  remaining  useless,  of  which  18  per  cent 
were  amputated. 

For  injuries  about  18  were  perfect,  about  65  useful,  and 
about  twelve  were  amputated. 

When  due  to  gunshot  injuries,  about  60  per  cent  were  use- 
ful, and  24  were  amputated,  the  remaining  not  accounted  for. 

When  done  for  deformity,  ig^  were  perfect,  and  about  68 
per  cent  had  useful  limbs;  the  remainder  not  reported. 

It  appears  that  the  degree  of  usefulness  does  not  depend 
upon  the  amount  of  bone  removed. 


Fig.  239. 

The  removal  of  the  patella  increased  the  usefulness  over 

the  retention  about  45  per  cent. 

Contiguous  Anatomy. — The  articular  vessels  and  those  which 
occupy  the  popliteal  space  are  the  ones  to  be  avoided.  The 
latter  are  separated  from  all  danger  by  the  dense  and  un- 
yielding ligamentum  posticum  Winslowii.  The  former  can 
be  avoided  by  limiting  the  incisions  to  the  space  between 
the  origin  and  insertion  of  the  lateral  ligaments.  There 
are  two  well-known  methods  of  excising  this  joint:  i.  The 
non-subperiosteal,  or  the  ordinary  method;  and  2,  the  sub- 
periosteal. The  former  is  employed  when  the  tissues  are 
too  extensively  destroyed,  or  diseased  to  admit  of  the  saving 
of  the  periosteum. 


EXCISION   OF  KNEE. 


241 


Non-subperiosteal  Excision  of  the  Knee  Joint. — Flex  the  leg 
to  a  right  angle  and  make  a  curved  incision,  beginning  at 
the  posterior  border  and  upper  portion  of  one  condyle, 
around  to  the  same  point  on  the  outer,  with  the  convexity- 
downward  and  corresponding  to  the  insertion  of  the  liga- 
mentum  patella  (Fig.  239).  This  incision  divides  the  tissues 
down  to  and  opens  the  anterior  portion  of  the  capsular 
ligament.  The  limb  should  now  be  still  more  strongly  flexed 
and  the  lateral  and  crucial  ligaments  divided.  A  retractor 
is  then  passed  between  the  ligamentum  posticus  and  the 
posterior  surface  of  the  femur,  the  bone  pushed  forward 
and  cut  off  on  a  line  parallel  with  the  articular  surface,  pro- 
vided the  extent  of  the  diseased  bone  will  admit  of  it.  The 
head  of  the  tibia  is  then  treated  in  the  same  manner,  being 
careful  to  avoid  the  articulation  of  the  fibula. 

In  this  operation  it  is  better  to  re- 
move the  patella,  since  its  means  of 
attachment  (the  ligamentum  patel- 
la) has  been  severed.  All  inflamed 
and  degenerated  synovial  membrane 
should  be  dissected  away. 

The  bony  surfaces  should  now  be 
united  by  passing  annealed  iron 
wire  or  silver,  through  the  con- 
tiguous lateral  borders;  the  wound 
is  then  washed  with  the  strong  car- 
bolic solution  and  a  drainage  tube 
passed  from  side  to  side  through  the 
joint  behind  the  bones;  the  whole  en- 
veloped in  the  antiseptic  dressing,  and 
the  limb  immovably  fixed  in  a  brack- 
eted plaster  splint,  properly  suspend- 
ed. In  sawing  through  the  exposed  ex- 
tremities of  either  bone,  the  line  of  in- 
cision must  be  made  to  include  the 
whole  of  the  diseased  osseous  tissue. 
The  line  of  section  through  the  bone 
last  sawn  must  correspond  in  direc-  Fig.  240. 

tion  and  be  parallel  with  the  line  of  section  through  the 
bone  to  which  its  sawn  surface  is  to  be  applied,  otherwise 
the  union  of  the  sawn  surfaces  will  cause  an  angular  de- 
formity (Fig.  240).  This  applies  more  particularly  to 
those  cases  where  anchylosis  in  the  straight  position  is 
sought.     If  for  any  reason  it  be  thought  better  to  anchylose 


242 


OPERATIVE   SURGERY. 


it  with  slight  flexion,  then   the   thicker  portion  should  be 
taken  from    the  posterior  parts  of  the  bone. 

Subperiosteal Exsectio7i  of  Kne-e  Joint. — Extend  the  limb  and 
make  a  curved  incision  (Langenbeck)  on  the  inner  side  from 
six  to  seven  inches  in  length,  with  the  convexity  downward, 
corresponding  to  the  posterior  border  of  the  condyles  and  its 
centre  to  the  line  of  articulation,  commencing  at  the  inner 
border  of  the  rectus  femoris  and  terminating  below  at  the 
crest  of  the  tibia  (Fig.  241).     If  the  parts  are  now  separated, 

the  vastus  internus  muscle  and  the 
tendons  of  the  adductor  magnus 
and  sartorius  will  be  seen  (Fig. 
242),  and  should  be  carefully 
avoided.  Divide  the  internal  lat- 
eral ligament  in  a  line  with  the 
articulation,  with  the  periosteal 
elevator,  separate  the  capsular 
ligament  from  the  anterior  surface 
of  the  inner  condyle  of  the  femur 
up  to  the  vastus  internus,  and  from 
the  tibia  forward  to  the  median 
line,  along  with  the  internal  alar; 
extend  the  leg  slowly  and  at  the 
same  time  dislocate  the  patella 
outward  by  the  thumb  applied 
to  the  inner  border;  divide  the 
crucial  ligaments,  also  the  exter- 
nal lateral,  and  the  corresponding 
portion  of  the  capsular  by  a  semi- 
lunar incision  carried  a  few  lines 
below  the  tip  of  the  external  con- 
dyle. Divide  the  posterior  por- 
tion of  the  capsule  and  force  the 
extremities  of  the  femur  and  tibia 
successively  through  the  wound, 
and  saw  them  as  before.  The 
patella  remains  unmolested,  except  it  be  diseased,  when 
the  diseased  portion  is  removed  with  a  gouge,  or  the 
bone  can  be  enucleated  from  the  periosteal  surroundings 
by  the  elevator  and  scalpel.  A  small  opening  should 
now  be  made  at  the  outer  side  of  the  joint,  for  the  purpose 
of  establishing  thorough  drainage.  A  drainage  tube  should 
be  passed  through  the  upper  synovial  pouch,  or  firm  com- 
pression be  made  thereon  to  prevent  the  collection  of  inflara- 


FlG. 


EXCISION   OF  KNEE. 


243 


matory  products.  It  is  then  cleansed,  all  hemorrhage 
stopped,  surrounded  by  antiseptic  dressing,  and  immovably 
fixed  till  future  dressings  become  necessary. 


_  .gracUii 
—  fimimtmSA 


Fig.  242. 

T^e  subperiosteal  of  Oilier  is  made  through  an  incision 
commencing  two  inches  above  and  to  the  outer  side  of  the 
patella,  carried  down  to  its  upper  and  outer 
angle,  along  the  outer  border  to  the  apex  and 
outer  side  of  the  ligamentum  patella  below  its 
insertion,  through  the  superimposed  tissues 
(Fig.  243).  The  outer  condyle  of  the  femur  is 
denuded  of  its  periosteum  along  with  the  later- 
al and  capsular  ligaments  and  the  outer  head 
of  the  gastrocnemius;  the  anterior  surface  of 
the  femur  is  denuded,  the  crucial  ligaments 
cut,  patella  displaced  inward  over  the  inner 
condyle,  the  leg  is  then  flexed  and  carried  in- 
ward; causing  the  femur  to  protrude,  when 
it  is  isolated  and  sawn  off.  The  upper  end  of 
the  tibia  is  then  denuded  from  above  down- 
ward, pushed  through  the  opening  and  like- 
wise divided.  If  the  patella  be  diseased,  re- 
move it,  leaving  its  periosteum  behind. 

Excision  of  the  Patella. — It  may   be   neces- 
sary,   on   account   of   necrosis   or   injury,    to 


244  OPERATIVE   SURGERY. 

patella  independently  of  the  tibia  and  femur.  In  such 
cases  the  deep  incisions  must  correspond  in  extent  to  the 
diseased  bone-;  for  if  they  be  greater  the  synovial  cavity 
may  be  opened.  The  periosteum  should  be  raised,  dead 
bone  carefully  removed,  if  possible,  without  entering  the 
joint.  If  the  joint  be  not  involved,  recovery  will  be  speedy 
and  satisfactory  under  disinfectant  dressing,  with  the  limb 
confined  in  the  extended  position  till  sufficient  repair  has 
taken  place  to  warrant  flexion  without  fracture  of  the  bone. 
The  results  in  eleven  cases  are  two  deaths  and  nine  recov- 
eries, of  which  eight  were  complete  and  three  partial  ex- 
cisions. 

Excisions  of  the  Hip  Joint. — It  is  well  before  attempting 
this  operation  to  give  a  brief  survey  of  the  important  liga- 
ments and  muscular  attachments  to  be  respected.  The 
space  is  too  limited  to  describe  them  in  detail,  and  even 
to  do  so  would  hardly  be  in  keeping  with  the  scope  of  this 
work. 

The  ilio-femoral,  capsular,  cotyloid,  and  even  the  teres, 
should  be  carefully  considered  in  relation  to  their  origin 
and  insertion,  in  order  that  their  relations  with  the  involu- 
criypi  or  periosteum  may  be  maintained.  Those  muscles 
which  are  connected  with  the  trochanters  major  and  minor, 
should  likewise  be  preserved  intact,  in  order  that  their  as- 
sociation with  the  new  bone  growth  may  give  to  the  new 
joint,  so  far  as  possible,  the  normal  functions  of  the  old 
one.  The  results  of  this  operation  are  approximately 
as  follows:  90  per  cent  die,  when  done  for  gunshot  in- 
juries. Of  these,  the  greater  percentage  (48)  followed  the 
intermediate  operation;  15  per  cent  the  secondary,  and  the 
remainder  the  primar}^  For  disease  the  mortality  is 
reported  variously  from  15  (Sayre)  to  45  per  cent.  Is  best 
done  from  one  to  ten  years  of  age;  and  is  most  favorable 
when  it  has  existed  from  ten  to  fifteen  months.  A  greater 
number  die  from  complete  than  partial  excisions.  The 
rate  of  mortality  is  but  little  modified  by  the  removal  of 
the  trochanters,  and  even  the  upper  portions  of  the  shaft, 
diminishing,  however,  from  the  head  of  the  bone  down- 
ward, and  increasing  in  proportion  to  the  extent  of  the 
disease  of  the  ilium.  About  94  per  cent  secure  useful 
limbs,  when  excised  for  disease.  Complete  excision  is  fol- 
lowed by  a  more  useful  limb  than  partial. 

The  hip  joint  may  be  removed  with  or  without  the  pres- 
ervation of  the  periosteum;  giving  two  quite  distinct  forms 


EXCISION  OF  HIP. 


245 


of  operating,  i.  The  simple,  when  no  effort  is  made  to 
save  the  periosteum,  and  the  muscular  and  ligamentous 
attachments  are  freely  sacrificed.  This  method  is  applica- 
ble to  malignant  disease  of  the  bone,  and  to  injuries  caus- 
ing extensive  comminution  and  laceration.  In  the  latter 
case,  a  conscientious  search  will  often  be  repaid  by  finding 


Fig.  244. 

periosteal  tissue  and  muscular  attachments  worthy  of  care- 
ful preservation.  Under  all  circumstances  the  acetabulum 
should  be  carefully  scrutinized  for  the  presence  of  dead 
bone,  which  should,  in  all  instances,  be  removed  with  care, 
else  the  pelvic  contents  may  be  injured. 

Operation  (White). — The  simple  method  is  done  by  placing 


246 


OPERATIVE   SURGERY. 


the  patient  on  the  healthy  side,  and  making  a  deep  curved 
incision  (Fig.  244)  commencing  at  a  point  midway  between 
the  anterior  superior  spinous  process  of  the  ilium  and  the  tro- 
chanter major,  and  passing  backward  around  the  top  of  the 
trochanter,  down  its  posterior  border  about  three  inches: 
with  a  stout  knife  divide  the  insertions  of  the  muscles  con- 
nected to  the  great  trochanter  (Fig.  245),  draw  them  aside 


Fig.  245. 

with  a  spatula,  and  expose  the  posterior  surface  of  the  neck 
of  the  femur  and  the  acetabulum.  The  exposure  will  be  still 
more  complete  if  the  femur  be  rotated  strongly  inward. 
If  the  cotyloid  and  capsular  ligaments  be  now  divided,  and 
the  thigh  be  flexed  and  adducted,  the  head  of  the  bone  will 
be  raised  from  the  acetabulum  sufficiently  to  admit  of  the 
division  of  the  ligamentum  teres,  when  the  complete  escape 
of  the  head  of  the  fernur  will  take  place.     The  soft  part§ 


EXCISION   OF   HIP, 


247 


are  then  protected  by  the  spatula,  the  bone  exposed  the  re- 
quired extent,  and  sawn  off  (Fig.  246). 

Subperiosteal  Excision  of  the  Hip  Joint  (Langenbeck). — 
Place  the  patient  on  the  sound  side  with  the  thigh  flexed 
at  an  angle  of  45°;  make  an  incision  five  or  six  inches  in 
length  in  the  long  axis  of  the  great  trochanter  (Fig.  247) 


Fig.  346. 


upward  and  backward  towards  the  posterior  superior 
spine  of  the  ilium,  through  the  fibres  of  the  gluteus  maxi- 
mus,  fascia  lata,  and  periosteum  of  trochanter;  separate 
the  surfaces  of  the  wound  with  retractors,  and  with  the  ele- 
vator and  knife  raise  the  periosteum  and  the  attachments  of 
the  muscles  inserted  into  the  trochanter  major  and  the  con- 
tiguous surfaces,  being  careful  to  preserve  their  connections 
with  each  other;  next  make  a  longitudinal  incision  along 
the  neck  of  the  femur,  through  the  capsular  ligament  and 


248 


OPERATIVE   SURGERY, 


the  periosteum.  The  periosteum  of  the  neck  is  then  sepa- 
rated in  connection  with  the  attachments  of  the  capsular 
ligament,  and  the  obturator  externus  in  the  same  manner 
as  before.  If  a  piece  be  now  cut  from  the  cotyloid  liga- 
ment, and  the  thigh  be  rotated  inward  and  adducted,  the 
head  of  the  bone  will  be  elevated  from  the  floor  of  the  aceta- 
bulum sufficiently  to  admit  of  the  division  of  the  ligamen- 
tum  teres,  when  it  can  be  pushed  through  the  opening  and 
sawn  off. 

The  following  admirable  method  of  excision  is  recom- 


mended by  Prof.  Lewis  A.  Sayre.     It  is  subperiosteal  in 

all  essential  particulars,  and  possesses  an  advantage  over 
the  one  just  described  in  that  the  primary  incision  is  better 
adapted  to  drainage.  Place  the  patient  on  the  sound  side 
and  introduce  a  strong  knife  dov/n  to  the  bone,  midway 
between  the  anterior  spinous  process  of  the  ilium  and  top 
of  the  trochanter  major;  carry  it  in  a  curved  course  upon 
the  bone  to  the  top  of  the  great  trochanter  midway  between 


EXCISION  OF  tin?. 


m 


its  posterior  border  and  centre;  complete  it  by  carrying 
the  knife  forward  and  inward,  making  the  length  of  the 
incision  from  four  to  six  or  eight  inches,  depending  upon 
the  size  of  the  thigh  (Fig.  248).  If  it  be  not  certain  that  the 
periosteum  of  the  trochanter 
be  divided  by  the  first  in-^ision, 
the  knife  should  be  carried 
along  the  same  line  a  second, 
and  even  a  third  time  if  needs 
be.  The  soft  parts  are  now' 
drawn  asunder,  exposing  the 
great  trochanter,  when,  with  a 
narrow,  thick  knife,  a  second 
incision  is  made  through  the 
periosteum  only,  at  right  an- 
gles with  the  first,  about  an 
inch  or  an  inch  and  a  half  from 
the  top  of  the  trochanter.  At 
the  junction  of  the  periosteal 
incisions  introduce  the  blade  of 
the  elevator,  and  carefully  peel 
the  periosteum  from  either  side 
as  far  as  possible,  together 
with  the  ligamentous  attach- 
ments, until  the  digital  fossa 
is  reached.  The  insertions  of 
the  rotators  into  the  trochanter 
major  and  digital  fossa  are  so  firm  that  it  will  be  impossi- 
ble to  peel  them  off;  they  must  be  carefully  separated  by 
short  parallel  cuts,  so  directed  as  to  remove  the  periosteum 
with  which  they  are  blended.  After  the  separation  of  the 
tendinous  insertions,  continue  to  elevate  the  membrane 
upon  either  side  of  the  neck,  using  great  care  not  to  rup- 
ture it.  Its  integrity  is  important  to  prevent  infiltration 
into  the  surrounding  tissues,  provide  attachments  for  the 
important  ligaments  and  muscles,  also  as  the  basis  for  the 
reproduction  of  bone  which  is  hoped  will  take  place;  each 
of  which  will  exert  an  important  influence  in  the  formation 
of  a  useful  joint.  Having  separated  the  periosteum  so  far 
as  safely  can  be  done,  adduct  the  thigh  carefully  when  it 
will  be  raised  from  the  acetabulum,  and  the  remaining  por- 
tion can  be  detached.  Adduct  and  depress  the  femur 
slightly,  being  careful  not  to  tear  the  periosteum,  lift  the 
head  of  the  bone  out  far  enough  to  admit  of  a  division  just 


Fig.  248. 


250  OPERATIVE  SURGERY. 

above  the  trochanter  minor;  care  should  be  taken  to  not 
expose  a  greater  surface  than  is  necessary,  since  necrosis 
will  follow  and  hinder  recovery.  It  is  better  to  remove  the 
trochanter  major,  even  though  it  be  not  diseased,  since  it 
will  impede  the  escape  of  discharges,  and  is  not  essential 
to  a  useful  limb  if  its  periosteal  covering  and  muscular  at- 
tachments have  been  preserved.  In  all  cases  after  the 
operation,  the  wound  should  be  well  irrigated  with  a  strong 
solution  of  carbolic  acid,  thoroughly  smeared  with  balsam 
of  Peru,  and  loosely  filled  with  fine,  well-shaken  oakum; 
good  drainage  provided,  and  extension  applied  to  the  limb 
either  by  the  Buck's  apparatus  or  the  wire  breeches. 

Excision  of  the  Great  Trochanter. — This  is  occasionally  re- 
quired on  account  of  caries.  A  longitudinal  or  curved  in- 
cision is  made  down  upon  the  bone,  which  is  removed  with 
the  usual  instruments.  The  circumflex  branches  and  the 
capsular  ligament  are  to  be  avoided. 


Fig.  249. 

Excision  of  the  Calcaneum. — It  is  important  that  as  much 
as  possible  of  the  bone  be  saved,  as  it  forms  the  posterior 
pillar  of  the  arch  of  the  foot,  also  the  attachment  of  the 
tendo-Achilles,  which  exerts  a  powerful  influence  in  locomo- 
tion. When  gouging  fails  to  remove  the  diseased  tissue, 
excision  becomes  the  final  resort.  A  horseshoe-shaped 
incision  is  carried  from  a  little  in  front  of  the  calcaneo- 
cuboid articulation  around  the  base  along  the  side  of  the 
foot  to  a  corresponding  point  on  the  opposite  side.  This 
flap,  with  the  knife  hugging  the  bone,  is  dissected  up,  ex- 
posing its  entire  under  surface  (Fig.  249).  A  second 
perpendicular  incision  about  two  inches  in  length  is  then 
made  through  the  middle  of  the  tendo-Achilles  down  to  the 
preceding  one  ;  the  resulting  flaps  are  dissected  off  closely 
to  the  bone,  and  the  posterior  articulation  between  the  cal- 


OSTEOTOMY.  25 1 

caneum  and  the  astragalus  opened,  the  ligamentous  con- 
nections severed,  together  with  those  between  it  and  the 
contiguous  bones,  the  os  calcis  taken  away,  and  any  ad- 
ditional diseased  bone  removed.  The  larger  majority  of 
cases  recover  with  useful  limbs. 

Excision  of  the  Astragalus. — This  is  accomplished  through 
a  semilunar  opening,  with  the  convexity  downward,  ex- 
tending between  the  malleoli  in  front.  The  tendons  of 
the  extensor  muscles  must  be  carefully  pushed  aside;  its 
connections  with  the  tibia,  fibula,  and  os  calcis  severed; 
finally,  those  with  the  scaphoid  ;  when,  with  the  foot  ex- 
tended, the  bone  is  pulled  from  its  site  and  the  calcaneum 
4)laced  in  the  resulting  gap  between  the  malleolus.  About 
75  per  cent  of  these  cases  recover  with  useful  limbs. 


OSTEOTOMY. 


In  a  liberal  acceptation,  osteotomy  may  be  defined  as  a 
section  of  bone. 

In  a  limited  sense,  however,  it  is  applied  to  the  divisions 
of  bone  that  may  be  attempted  for  the  relief  of  deformity, 
dependent   on   anchylosis,  rickets,  badly  united   fractures, 


Fig.  250. 


etc.,  etc.     It  may  be  done  either  with  or  without  antisep- 
tics.    The  latter,  however,  is  by  far  the  better  plan. 

The  instruments  employed  consist  of  especially  designed 
saws,  chisels,  osteotomes,  mallets,  scalpels,  blunt  hooks, 
and  sand  pillows.  .  ..... 


252 


OPERATIVE   SURGERY. 


There  are  various  forms  of  saws  employed,  named  usually 
after  the  one  who  designed  them.  Langenbeck  (Fig.  250), 
Adams  (Fig.  251).  The  blade  is  short  and  strong;  one  fourth 
of  an  inch  in  width  and  an  inch  and  a  half  in  length,  con- 
nected to  the  handle  by  a  strong  shank  three  inches  long. 
Deviations  from  this  one  are  to  meet  especial  indications, 
rather  than  to  abrogate  its  use. 

The  objections  to  the  use  of  the  saw  not  only  apply  to 


Fig.  251. 

the  danger  of  lacerating  the  contiguous  tissue,  but  more 
forcibly  to  the  retention  in  the  wound  of  the  bone-dust, 
which,  failing  to  be  absorbed,  is  followed  by  suppuration. 
The  saw  devised  by  Dr.  George  F.  Shardy,  of  this  city,  is 
the  best,  and  is  described  as  follows  by  himself: 


Fig.  252  (i,  2,  and  3). 

Figs.  252  and  253.  The  instrument  consists  of  a  trocar 
(Fig.  i)  and  a  staff  (Fig.  2),  with  a  handle  and  blunt  ex- 
tremity. A  portion  of  this  shaft  at  a  short  distance  from 
the  extremity  is  flattened,  one  edge  (B)  being  made  into  a 
knife  blade,  and  the  other  (C)  being  provided  with  saw- 
teeth. This  shaft  (Fig.  2)  is  intended  to  replace  the  trocar  in 
the  canula  after  the  latter  is  introduced.  When  in  position 
(Fig,  3)  either  the  saw  (C)  or  the  knife  (B)  edge  of  the 


§HRADY*S   SAW. 


253 


shaft,  according  to  the  way  the  latter  is  turned,  corresponds 
with  the  opening  of  the  canula.  The  saw  or  knife  can  then 
be  worked  to  and  fro  within  the  canula  by  a  piston-like 
movement,  the  canula  being  steadied  by  grasping  the  flange 
(D)  at  its  base.  If  it  be  necessary 
to  work  the  instrument  as  an  or- 
dinary blunt-pointed  sheathed  saw 
or  knife,  the  shaft  can  be  fixed  in 
the  canula,  and  made  into  one 
piece  by  a  thumb-screw  in  the 
handle.  The  portion  of  the  canu- 
la at  the  back  of  the  opening  is 
made  extra  strong,  and  is  of  the 
same  thickness  as  the  blade,  so  that 
in  sawing  there  is  no  stoppage  of 
the  passage  of  the  instrument 
through  any  thickness  of  the  bone. 
The  soft  parts  are  protected  from 
injury,  no  matter  which  way  the 
instrument  may  be  worked.  The 
saw-blade  is  blunt  at  its  extremity, 
and  is  guarded  on  all  sides  except 
in  its  limited  cutting  surface.  The 
same  may  be  said  of  the  knife. 
The  working  of  the  saw  to  and  fro 
in  the  canula  is  sufficient  in  sweep 
to  insure  the  division  of  any  bone 
having  a  diameter  less  than  the 
cutting  edge.  Still,  as  this  pro- 
cess is  much  slower  than  when 
the  saw  is  used  in  the  ordinary 
way,  it  ts  perhaps  better  to  restrict 
its  employment  to  operations  on  the 
smaller  bones,  to  cramped  localities, 
and  to  situations  where  there  is 
special  danger  of  wounding  some 
neighboring  vessels.  All  that  is 
necessary  in  using  this  saw  is  to 
thrust  the  trocar  and  canula  into 
the  limb,  the  fenestrum  of  the  can- 
ula being  alongside  of  the  bone  upon  which  the  operation 
is  to  be  performed.  The  trocar  is  then  withdrawn,  the 
staff  introduced  in  its  place  (Fig.  3),  and  worked  as  already 
described. 


Fig.  253. 


254 


OPERATIVE  SURGERY. 


Since  the  above  description  was  written  the  instrument 
has  been  slightly  modified  by  lessening  the  size  of  the  fe- 
nestrum  through  which  the  teeth  of  the  saw  are  seen,  which 
strengthens  the  canula  and  facilitates  its  progress  through 
the  bone  (Fig.  253). 

The  Chisel  is  like  that  of  the  carpenter,  but  differing  in 
its  temper;  it  has  two  parallel  sides  extending  to  its  cutting 


Fig.  254. 

edge.  The  cutting  surface  has  one  side  straight  and  the 
other  bevelled;  it  should  be  one  eighth  of  an  inch  thick  at 
the  base  of  the  bevel.  If  thicker,  it  may  splinter  the  bone. 
The  breadth  varies  according  to  the  size  of  the  bone,  one 
half  an  inch  is  suitable  in  the  majority  of  cases.  For  nar- 
row bones  one  fourth  inch  is  better  (Fig.  254).  The  width 
should  always  be  less  than  the  bone  to  be  attacked. 


INSTRUMENTS  FOR   OSTEOTOMY.  2^5 

The  temper  of  the  tools  of  the  hard-wood  or  ivory  turner 
is  best  suited  for  the  purpose,  and  its  efficiency  should  be 
tested  upon  the  thigh-bone  of  an  ox  or  other  animal  before 
using. 

Its  edge  should  be  sharp,  leaving  a  smoothly  cut  sur- 
face. This  instrument  is  employed  only  to  remove  a  wedge- 
shaped  piece  from  the  bone,  since  the  shape  of  its  cutting 
extremity  will,  as  with  the  carpenter's  chisel,  cause  it  to  go 
awry  if  a  straight  section  be  attempted. 

The  Osteotome. — This  instrument  is  bevelled  on  both  edges 
(see  Fig.  254),  resembling  a  slender  wedge;  the  handle  and 
the  blade  forming  one  piece.  The  top  should  have  a  round 
head,  against  which  the  thumb  is  pressed  to  steady  it. 
One  border  of  the  blade  is  delicately  marked  in  inches  to 
determine  the  depth  of  the  incision.  The  edge  should  be 
sharp  enough  to  cut  the  finger-nails,  and  the  temper  of  a 
character  to  withstand  the  strain  required.  It  can  be  tested 
upon  the  thigh-bone  of  the  ox;  when,  if  it  neither  turn  nor 
chip,  it  is  calculated  to  withstand  the  test  of  human  bone. 
Osteotomes  should  vary  in  thickness,  in  order  that  a  section 
begun  by  one  of  a  given  thickness  may  be  continued  on  its 
withdrawal  by  the  substitution  of  one  of  a  lesser  thick- 
ness. 

The  Mallet  is  made  of  hard  wood,  and  can  be  constructed 
for  the  purpose;  or,  an  extemporized  one  maybe  employed. 

The  Scalpel  is  an  ordinar}'  one,  with  a  sharp  point  suitable 
for  penetrating  at  once  to  the  bone.  Blunt  hooks  to  draw 
the  cut  asunder  are  employed,  without  force. 

The  Sand  Pillow. — Its  dimensions  should  be  about  eigh- 
teen inches  by  twelve;  made  of  stout  cloth,  and  filled  suffi- 
ciently to  permit  its  contents  being  moved  from  one  part  of 
the  bag  to  another,  without  leaving  a  portion  empty.  It 
should  be  dampened  before  being  used,  covered  with  car- 
bolized  cloth,  and  the  limb  laid  upon,  or  rather  embedded 
in  it.  It  forms  an  efficient  support,  and  prevents  the  force 
imparted  to  the  bone  by  the  mallet  injuring  the  soft  parts. 

The  opening  through  the  soft  parts  leading  down  to  the 
point  of  proposed  section  should  be  limited  in  extent,  and  so 
located  as  to  avoid  the  division  of  vessels,  or  injury  to  a  joint. 
It  should  be  made  in  the  long  axis  of  the  fibres  of  any  mus- 
cle through  which  it  passes  when  practicable,  down  to,  but 
not  through  the  periosteum.  The  scalpel  should  remain  in 
the  incision  till  the  danger  of  muscular  contraction  ceases, 
and  then  the  chisel  or  osteotome  is  passed  into  the  incision 


256 


OPERATIVE   SURGERY. 


by  the  side  of  the  blade,  as  a  guide,  when  it  can  be  with- 
drawn. 

It  is  better  that  the  wound  be  large  enough  to  admit  the 
finger,  or  even  to  permit  inspection  of  the  bone,  than  that 
the  tissues  around  a  small  incision  be  treated  with  violence, 
in  the  effort  to  accomplish  the  purpose. 

If  chips  of  bone  are  to  be  removed,  a  larger  incision  is  re- 
quired than  if  a  simple  section  be  intended.  The  patient 
should  in  all  instances  be  anaesthetized  and  the  limb  ren- 
dered bloodless  by  the  elastic  bandage  of  Esmarch  or  Mar- 
tin. All  cutting  instruments  employed  must  be  made  anti- 
septic, and  in  all  other  respects  the  operation  must  be  per- 
formed with  antiseptic  care. 

Subcutaneous  Division  of  the  Neck  of  the  Femur  (Adams). 
— Place  the  patient  upon  the  side,  with  the  bone  to  be  op- 
erated upon  uppermost.  Introduce  a  long  slender  scalpel 
or  tenatome  above  the  top  of  the  great  trochanter,  straight 
down  to  the  neck  of  the  femur;  di- 
vide the  muscles  and  open  the  cap- 
sule freely  on  the  anterior  and  upper 
surface;  pass  the  small  saw  by  the 
side  of  the  knife  along  the  track 
down  to  the  anterior  surface  of  the 
neck, which  is  then  sawed  transversely 
~  through  (Fig.  255)  sufficiently  from 
before  backward  to  be  easily  broken. 
The  limb  is  then  placed  in  position, 
the  wound  irrigated  with  a  solution 
of  carbolic  acid  (i  to  20),  to  render  it 
aseptic  and  wash  out  the  bone-dust; 
hemorrhage  checked,  a  small  drain- 
age tube  introduced,  the  remaining 
portion  of  the  incision  closed,  the 
whole  enveloped  in  antiseptic  dress- 
ing, and  the  limb  placed  in  an  im- 
Such  tendinous  contractions  as  inter- 
fere with  the  limb  being  placed  properly,  should  be  severed 
subcutaneously. 

This  operation  has  been  successful  in  thirty-one  out  of 
thirty-four  cases. 

Maunder,  Billoth,  and  others  have  used  the  chisel  with 
forcible  fracture  with  good  results.  Another  method 
(Volkmann)  consists  in  forming  a  false  joint  in  the  follow- 
ing manner: 


Fig.  255. 
movable  position. 


OSTEOTOMY. 


257 


Make  an  incision  along  the  posterior  surface  of  the  great 
trochanter,*  and  divide  the  bone  one  inch  below  its  upper 
border;  fracture  the  interior  of  the  neck  of  the  femur  and 
scoop  out  the  acetabulum  with  a  gouge.  Round  off  the 
upper  end  of  the  femur,  reducing  it  to  the  size  of  the  shaft 
below,  and  place  it  in  the  cotyloid  cavity;  apply  extension 
to  the  limb,  and  make  early  passive  motion.  Volkmann 
has  done  this  operation  several  times,  resulting  in  useful 
limbs  in  each  instance. 

Inter-irochanteric  Osteotomy. — This  operation  consists  in  ex- 
posing the  anterior,  outer,  and  posterior  surfaces  of  bone 
through  an  incision  about  six  inches  in  length,  beginning 
just  above  the  tip  of  the  trochanter  major,  and  carried  lon- 
gitudinally through  the  centre  of  its  outer  surface.  A 
short,  transverse  incision  is  then  joined  to  the  centre  of  the 
posterior  lip  of  the  first;  the  respec- 
tive surfaces  are  then  exposed  with 
an  elevator  until  the  trochanter 
minor  can  be  felt,  when  a  chain  saw 
is  passed  around  the  bone  immediate- 
ly above  this  process.  The  upper- 
most, or  curved  incision  (Fig.  256)  is 
made  by  first  sawing  upward  and 
outward,  until  the  bone  is  one  half 
severed,  then  changing  the  direction 
downward  and  outward  and  com- 
pleting the  section. 

The  second  section  is  made  by 
sawing  directly  through  the  bone  in 
its  transverse  axis,  removing  a  piece 
one  eighth  of  an  inch  thick  at  its 
outer  and  posterior  border,  and  three  fourths  of  an  inch  of 
its  central  part. 

The  upper  end  of  the  lower  fragment  is  then  rounded 
to  fit  the  concavity  above.  The  limb  is  straightened  out  and 
treated  like  a  compound  fracture. 

This  method  was  practiced  by  Dr.  Sayre  some  time  since 
with  eminent  success. 

The  removal  of  a  disk  of  bone  in  this  situation  has  been 
quite  frequently  practiced,  but  with  indifferent  success. 
Out  of  the  17  cases  reported,  7  died.  While  this  method 
displayed  great  ingenuity  and  resource  on  the  part  of  the 


Fis.  256. 


*  Ceatralblatt  Chirurgie,  Jan.  31st,  1880. 


258  OPERATIVE   SURGERY. 

originator,  the  fatality  attending  it,  together  with  the  intro- 
duction of  the  chisel  and  osteotome,  render  it  at  the  pres- 
ent time  impracticable. 

The  modification  introduced  by  Volkmann  in  1873  con- 
sists in  making  an  incision  along  the  posterior  surface  of 
the  great  trochanter  and  removing  the  periosteum  from 
two  thirds  of  its  circumference,  when  with  chisels  and 
gouges  a  triangular  piece  is  taken  from  just  below  the 
trochanter,  the  bone  broken,  straightened,  and  placed  in 
proper  position  until  union  has  taken  place.  Of  the  twelve 
operations  thus  performed,  all  recovered. 

Osteotomy  for  Bony  Anchylosis  of  Knee  Joint  (supra-con- 
dyloid). — Make  a  longitudinal  incision,  sufficient  to  admit 
the  osteotome,  at  the  outer  side  of  the  rectus  tendon,  one 
finger's  breadth  above  the  upper  portion  of  the  outer  con- 
dyle. The  osteotome  is  introduced,  and  turned  so  its  cut- 
ting surface  corresponds  to  the  transverse  axis  of  the  bone 
at  the  point  to  be  divided;  with  the  limb  resting  up  on  the 
sand-bag,  the  bone  is  two  thirds  divided  and  the  remainder 
broken  or  bent.  If  performed  from  the  inner  aspect,  the  in- 
cision is  made  along  the  anterior  border  of  the  tendon  of 
the  adductor  magnus,  beginning  one  inch  above  the  inser- 
tion. The  remaining  steps  of  the  operation  are  similar  to 
the  preceding.  It  may  be  necessary  to  supplement  the  sec- 
tion of  the  femur  with  that  of  the  tibia,  in  order  to  correct 
the  deformity  sufficiently.  This  is  done  by  making  an  in- 
cision through  the  skin  over  the  tibial  crest  just  below  the 
tuberosity.  Through  this  opening,  the  subcutaneous  and 
posterior  surfaces  of  the  tibia  are  divided  sufficiently  to 
admit  of  a  fracture  and  the  consequent  correction  of  the 
deformity.  The  fibula,  owing  to  its  mobile  association  with 
the  tibia,  does  not  require  division.  It  is  often  necessary, 
however,  to  cut  the  hamstring  tendons  before  the  deformity 
can  be  properly  corrected.  Supra-condyloid  osteotomy  has 
yielded  most  satisfactory  results.  In  522  operations  for  all 
causes,  not  a  single  death  attributable  to  it  has  occurred. 
All  of  the  patients  were  benefited,  and  many  were  able  to 
take  an  active  part  in  affairs  from  which  they  had  been  de- 
barred. 

Supra-co7idyloid  osteotomy  for  Genu  Valgum  (Fig.  257). — In 
this  operation  care  is  taken  to  avoid  the  popliteal  vessels, 
anastomotica  magna,  superior  internal  articular  arteries, 
and  the  synovial  pouch.  The  incision  in  the  soft  parts  is 
rn^de  at  the  inner  side  of  the  limb,  beginning  a  finger's 


OSTEOTOMY. 


259 


breadth  above  the  tendon  of  insertion  of  the  adductor  mag- 
nus  into  the  upper  portion  of  the  internal  condyle  and  half 
an  inch  in  front  of  it,  and  carried  upward  sufficiently  to 
admit  the  osteotome.  The  course  of  this  incision  avoids 
as  far  as  possible  any  interference  with  the  anastomotica 
magna  and  the  articular  b'-anches.  The  osteotome  is  applied 
to  the  bone  transversely  at  the  point  indicated  by  the  dotted 
line  in  Figure  258,  and  so  directed  that  its  course  will  cor- 
respond to  a  line  extending  across  the  posterior  surface  of 
the  femur  to  a  point  one  finger's  breadth  above  the  external 
condyle.  The  extent  of  the  osseous  incision  depends  upon 
the  density  of  the  bone  ;  if  the  subject  be  young,  it  can  be 
bent  or  broken,  if  it  be  cut  through  two  thirds  of  its  diame- 


FiG.  357. 


Fig.  958. 


ter.  If  it  be  dense,  it  will  be  necessary  to  carry  the  inci- 
sion to  the  outer  wall.  The  posterior  and  inner  surfaces  of 
the  bone  are  cut,  if  necessary,  using  a  finer  chisel  to  com- 
plete the  operation.  When  the  bone  is  sufficiently  divided, 
the  limb  is  straightened,  all  hemorrhage  arrested,  and  the 
limb  treated  as  before  indicated.  The  following  figures 
will  aid  in  explaining  the  method  : 

Fig.  259  shows  a  long  internal  condyle  in  genu  valgum  ; 
Fig.  260  a  section  through  about  three  fifths  of  its  diameter; 
Fig.  261  the  appearance  of  the  bone  with  the  limb  placed 
in  position,  showing  the  curvature  rectified.  The  results 
Qf  this  operation,  with  reference  to  usefulness  of  the  limb. 


26o 


OPERATIVE   SURGERY. 


cure  of  the  deformity,  and  danger  to  life,  are  most  flatter- 
ing. 

Osteotomy  for  Genu  Varum. — In  this  deformity  the  opera- 
tive proceedings  are  directed  to  the  outer  instead  of  the 
inner  side  of  the  bones  of  the  leg  and  thigh.  The  proced- 
ure, precautions,  and  treatment  are  similar.  The  division 
of  bones  through  a  small  external  opening  can  be  applied 
almost  indiscriminately  to  such  as  present  this  deformity, 
always  remembering  that  thorough  and  complete  antisep- 
tic precautions  should  be  taken.  The  results  are  most  flat- 
tering, and  commend  it  to  the  consideration  and  practice  of 
the  profession. 

Bow-legs. — Genu  varum  may  depend  on  an  outward 
curvature  of  the  bones  of  the  leg,  wholly  or  in  part.     In 


Fig.  259. 


Fig.  360. 


Fig.  261 


either  instance  the  deformity  can  be  corrected  by  a  sub- 
cutaneous osteotomy  of  the  tibia.  If  the  patient  be  young 
enough  a  green-stick  fracture  of  the  fibula  will  obviate  the 
use  of  the  osteotome  upon  it. 

Operation. — Make  a  longitudinal  incision  at  the  point  of 
greatest  curvature,  an  inch  or  so  in  length,  midway  between 
the  borders  of  the  subcutaneous  portion  of  the  bone.  Sepa- 
rate the  tissues,  introduce  the  osteotome  and  cut  the  bone 
transversely  until  the  remaining  portion  can  be  fractured. 
Cut  or  bend  the  fibula,  correct  the  deformity,  and  treat 
antiseptically.  It  is  sometimes  necessary  to  divide  the  bone 
in  two  situations  to  secure  good  position.  If  so,  it  should 
be  done  at  another  time,  and   at  the  remaining  point  of 


OSTEOPLASTY — AMPUTATIONS.  261 

greatest  convexity.    It  is  much  safer  to  cut  both  tibiae  than 
to  divide  either  in  two  situations  at  the  same  time. 


OSTEOPLASTY, 

Or  transplantation  of  bone. 

This  has  not  gained  the  prominence  as  a  surgical  expedi- 
ent that  the  knowledge  of  the  laws  governing  the  growth 
of  bone  bids  fair  to  lead  to. 

Bone  associated  with  its  periosteal  and  fibrous  connec- 
tions, has  been  transferred,  as  in  the  case  of  the  operation 
on  the  hard  palate  for  the  closure  of  a  fissure,  also  the  clos- 
ure of  the  spaces  between  the  ununited  fragments  of  bone, 
by  the  filling  of  them  with  freshly  sawn  sections  from  the 
main  shaft.  The  conditions  necessary  to  a  successful  issue 
of  this  operation  are  exceedingly  numerous  and  exacting. 


AMPUTATIONS. 


Amputation  consists  in  the  removal  of  a  limb  either  in 
its  continuity  or  at  its  articulation.  The  aims  sought  to 
be  gained  by  an  amputation  are  :  i.  The  saving  of  the  life 
of  the  patient.     2.  The  securing  of  a  serviceable  limb. 

If  the  prospects  of  recovery  be  annulled  by  the  presence 
of  a  badly  diseased  or  mangled  limb,  it  is  no  opprobrium 
upon  the  Art  to  remove  it.  If  a  limb  be  so  badly  injured  or 
diseased  as  to  require  removal,  it  is  entirely  proper  that  the 
ability  of  the  designer  of  compensative  appliances  be  con- 
sidered, that  the  patient  may  reap  the  combined  benefit  of 
the  art  of  the  surgeon  and  the  ingenuity  of  the  mechanic. 
A  stump,  to  be  serviceable,  should  be  sound,  unirritable, 
with  a  good  circulation  and  abundant  leverage.  The  first 
three  qualities  depend,  all  things  being  equal,  very  largely 
upon  its  length, shape,  and  vascular  supply  of  the  flaps;  the 
last  one  depends  entirely  upon  the  length  of  the  bone.  The 
flaps  should  be  movable  over  the  extremity  of  the  stump 
after  healing  is  completed,  not  tightly  drawn  and  smooth, 
like  a  base-ball  cover.     Flaps   tightly  drawn  at  the  initial 


262 


OPERATIVE   SURGERY. 


dressing  soon  become  more  so,  on  account  of  inflammatory 
action.  At  a  later  date,  the  normal  shrinkage  of  the  integu- 
ment draws  them  against  the  end  of  the  bone,  to  which  they, 
together  with  the  cicatrix,  become  immovably  united,  and 
form  a  good  basis  for  a  troublesome  stump.  The  proper 
length  of  the  flaps,  then,  becomes  an  important  point  in  es- 
timating the  prospective  usefulness  of  the  limb  and  comfort 
of  the  patient.  In  cases  where  they  can  be  made  of  similar 
lengths,  their  extent  should  correspond  to  about  one  fourth 
the  circumference  of  the  limb  at  the  point  where  the  bone  is 
to  be  divided.     If  one  flap  only  be  employed,  it  should  be 


Fig.  263. 


double  the  length  of  the  two.  Any  increase  in  the  length 
of  one  should  be  accompanied  by  a  proportionate  decrease 
in  the  length  of  the  other.  The  shape  of  the  flaps  largely 
controls  the  site  of  the  cicatrix.  It  is  advisable  that  the 
cicatrix  be  so  placed  as  not  to  be  subjected  to  pressure  or 
friction.  If,  however,  the  flaps  be  made  of  sufficient  length 
to  admit  of  the  formation  of  a  non-adherent  or  movable 
cicatrix,  its  location  is  a  matter  of  secondary  importance. 
The  length  and  location  of  the  flaps  also  largely  controls 
their  circulation.  If  they  be  too  long,  the  circulation  will 
be  enfeebled  ;  if,  on  the  contrary,  they  be  too  short,  the 
tension   will   become   the   greater  impediment,  causing  a 


AMPUTATIONS. 


263 


blue,    cold,  and    shiny    surface,    sensitive  to   the  slightest 
injury.     The  circulation  in  the  normal  limb,  or  a  portion 


Fig.  263. 

of  it,  may  be  such  as  to  predispose  to  a  small  and  sluggish 
blood  supply  in  flaps  constructed  from  it. 

Flaps   are   classified,    according   to   the   tissues   entering  into 
them;  into  the  cutaneous,  integumentary,  or  skin  flaps,  mus- 


264 


OPERATIVE   SURGERY. 


culo-cutaneous,  muscular,  and  periosteal.     The  integumen- 
tary is  commonly  employed  in  this  city. 

They   are   also   classified,     accordmg    to    their    shape^    into 
circular,   modified   circular,   oval,   rectangular,   hood,  etc. 


Fig.  264. 

The  oval  may  be  either  unilateral,  bilateral,  anterior,  or 
posterior.  Many  of  the  preceding  may  be  composed  of 
integument  alone,  or,  combined  with  muscular  tissue,  and 
even  periosteum. 

Circular  Method  (Fig.  262). — This  method  is  followed  by 


CIRCULAR  AMPUTATION. 


265 


an  admirable  stump,  is  easiest  of  performance,  and  con- 
sequently very  frequently  practised.  It  is  done  by  mak- 
ing a  circular  incision   transversely  around    the  long  axis 


Fig.  265. 

of  the  limb,  through  the  integument  and  subcutaneous  tis- 
sue down  to  the  muscles,  at  a  distance  below  the  proposed  di- 
vision of  the  bone,  corresponding  to  one  fourth  the  circum- 
ference of  the  limb  at  that  point.     The  flap  is  then  dissected 


266 


OPERATIVE   SURGERY. 


up  from  the  muscles  with  an  ordinary  scalpel;  its  edge 
being  directed  towards  the  muscles  (Fig.  263)  rather  than 
parallel  with  them  (Fig.  264),  as  the  latter  severs  the  capil- 
lary connection  between  the  integument  and  the  deeper 
tissues.  The  dissection  should  be  done  by  circular  sweeps, 
rather  than  mincing  cuts,  which  hack  the  tissues  and  pro- 
voke suppuration.  This  careful  manner  of  raising  the  flap 
applies  equally  to  all  of  the  varieties  which  involve  the 
separation  of  similar  tissues. 

If  the  limb  be  conical,  much  difficulty  will  be  experienced 
in  turning  over  the  sleeve  of  integument,  which  can  be  ob- 


FlG.  266. 

viated  by  making  a  longitudinal  cut  at  the  most  dependent 
portion. 

The  flap  should  be  turned  upward  to  the  point  where 
the  bone  is  to  be  divided;  then  with  the  catling  make  a  cir- 
cular division  of  the  muscles  down  to  the  bone  (Fig.  265); 
beginning  far  enough  below  the  reflection  of  the  flap  to 
allow  for  the  retraction  for  the  divided  muscles.  No  def- 
finite  law  can  be  assigned  to  this  element,  although  they  will 
contract  according  to  their  size,  length,  degree  of  irritabil- 
ity, etc.  The  suitable  point  of  section  will  appear  in  con- 
nection with  the  description  of  the   special  amputations, 


FLAP   AMPUTATION. 


267 


Not  infrequently  the  muscles  are  cut  just  below  the  reflec- 
tion of  the  flap,  as  in  Fig.  267;  this  is  not,  however,  as  good 
a  plan  as  the  former,  since  sensitive  stumps  are  more  liable 
to  result  therefrom.  The  bone  is  sawn  at  the  highest  point 
of  exposure. 

Modified  Circular  Method  (Fig.  267). — This  plan  was  sug- 
gested by  Mr.  Liston,  who  made  semilunar  flaps,  which  he 
dissected  up  to  their  point  of  junction  with  each  other, 
when  the  muscles  and  bone  were  divided,  as  in  the  circular 
method.  This  was  afterward  modified  by  Mr.  Symes,  who 
dissected  the  flaps  a  short  distance  above  their  point   of 


Fig.  267. 


juncture,  and  divided  the  muscles  and  bone,  as  before.  In 
either  instance,  however,  it  amounts  to  slitting  up  the  cuff  of 
a  circular  flap,  and  trimming  off  the  angles  caused  thereby. 

Oval  Method  is  in  reality  a  modified  circular,  slit  up  at 
one  side  and  the  angles  trimmed  off.  It  is  employed  princi- 
pally in  disarticulations,  and  will  be  described  in  connection 
with  those  operations. 

Single  Flap  Met/iod. — This  is  adapted  to  those  cases 
where  the  tissues  of  one  side  of  the  limb  only,  are  suitable 
for  the  purposes  of  a  flap;  as,  in  the  case  of  unilateral  lacer- 
ations, ulcerations,  etc.  This  flap  is  composed  of  the 
muscular  tissues  and  integument,  and  can  be  made  either 


268 


OPERATIVE   SURGERY. 


by  transfixion  or  division  from  without.  If  possible,  a 
short  convex  flap  is  made  on  the  opposite  side  of  the  limb. 
Dotible  Flap  Operation  is  made  by  transfixion,  and  includes 
the  muscles  down  to  the  bone  on  either  side  of  the  limb 
(Figs.  268  and  269).  The  tissues  to  be  transfixed  are  raised 
slightly  by  the  left  hand  of  the  operator,  who  then  enters 
the  point  of  the  knife  at  the  side  nearest  himself,  pushing 
it  through  slowly,  in  close  contact  with  the  anterior  surface 
of  the  bone,  slightly  raising  the  handle  as  it  passes,  thereby 
causing  its  point  to  emerge  at  the  opposite  side  of  the  limb 
at  a  point  exactly  opposite  to  its  entrance;  the  flap  is  then 
made  by  cutting  obliquely  upward  with  a  sawing  motion. 


and  269. 


It  is  pulled  backwards  by  an  assistant,  and  the  knife  is  re- 
inserted at  the  original  point  of  entrance,  carried  behind 
the  bone,  handle  depressed  to  cause  the  point  to  emerge  at 
the  same  situation  as  at  the  anterior  transfixion,  and  the 
posterior  flap  made  by  cutting  obliquely  downward.  Each 
flap  should  correspond  to  at  least  one  half  the  diameter  of  the 
limb.  The  retractor  is  then  applied,  and  all  the  soft  tissues 
are  drawn  well  upward;  the  remaining  fibres  in  contact 
with  the  bone  are  severed,  and  the  bone  carefully  sawn 
through.  If  lateral  flaps  be  made,  the  outer  should  be 
formed  first.  The  flap  containing  the  large  vessels  is  to  be 
last  divided. 


FLAP  AMPUTATIONS. 


269 


The  Mixed  Double  Flap  is  a  modification  of  the  preceding, 
and  sometimes  called  Sedillot's  method.  The  flaps  are 
made  by  transfixion,  as  before,  but  are  more  superficial; 
the  knife  not  being  brought  in  contact  with  the  bone.  The 
remaining  muscles  and  vessels  are  divided  by  a  circular  in- 
cision, and  the  rest  of  the  amputation  is  done  as  before 
described.  In  this  instance  the  flaps  are  thinner  and  shorter 
than  in  the  preceding. 

Langenbeck's  Method. — This  differs  from  the  last  only  in 
the  manner  of  obtaining  the  result;  the  flaps  being  cut 
from  without  inward,  which  affords  a  better  opportunity 


Figs.  270  afld  271. 

to  shape  them.  Another  combination  of  the  method  is 
made  by  cutting  the  anterior  flap  from  without  inward, 
and  the  posterior  by  transfixion. 

The  Rectangular,  or  Teale's  Method  (Figs.  270  and  271). — In 
this  two  rectangular  flaps  are  employed;  one  being  four 
times  longer  than  the  other;  both  flaps  include  the  struc- 
tures down  to  the  bones.  The  longer  flap  is  taken  from 
the  side  of  the  limb,  where  the  bone  is  the  most  superficial. 
The  shorter  contains  the  important  vessels.  Tlie  length  and 
breadth  of  the  long  flap  corresponds  to  half  the  circumfer- 


270 


OPERATIVE   SURGERY. 


enceof  the  limb  at  the  point  of  proposed  amputation.  The 
width  of  the  short  flap  is  a  half,  and  its  length  an  eighth  of 
the  circumference  of  the  limb.  Both  flaps  should  be  care- 
fully marked  out  before  beginning  the  operation.  This 
method  makes  an  admirable  stump,  but  sacrifices  fulcrum- 
age,  and  brings  the  bone  section  nearer  the  body  than  is  con- 
sistent with  the  additional  dangers  incurred.  Mr.  Lister 
recommends  that  the  longer  flap  be  made  a  third  and  the 
shorter  flap  a  sixth  of  the  circumference  of  the  limb,  which 
brings  the  cicatrix  at  the  edge  of  the  stump.  Also  that  the 
posterior  flap  consist  of  the  integument  and  subcutaneous 
tissues  alone.  This,  like  Teale's,  may  be  employed  when  the 
loss  of  tissues  is  greater  upon  one  side  than  upon  the  other. 
The  Hood  Flap. — There  is  no  substantial  difference  be- 
tween this  and  the  oval  method,  when  the  latter  is  slit  up 
at  the  most  dependent  part.  This  form  meets  the  indi- 
cations requisite  to  form  a  good  stump  as  well  as  any  other 
variety. 

Equilateral  Flaps  (Fig.  272)  consist  of  equilateral  skin 
.  flaps,  oval  in  outline,  the  posterior  incision 
being  made  further  up  the  limb,  to  im- 
prove the  drainage.  The  bone  is  divided 
above  the  anterior  point  of  junction  of 
the  flaps,  and  the  muscles  by  a  circular 
sweep  at  a  suitable  distance  below  the 
point  of  reflection  of  the  integumentary 
flaps. 

Periosteal  Flap. — This  consists  in  raising 
the  periosteum  in  conjunction  with  the 
tissues  which  rest  upon  or  are  attached 
to  it  sufficiently  to  cover  the  end  of  the 
divided  bones;  when,  it  is  allowed  to  fall 
into  place.  It  is  best  adapted  to  those 
bones  subcutaneously  located;  like  the 
tibia,  and  will  be  again  referred  to  in 
connection  with  amputations  of  the  leg. 

A  periosteal  flap  will,  if  it  becomes  ad- 
herent to  the  end  of  the  bone,  preserve  it 
from  atrophy,  and  lessen  the  danger  of 
the  formation  of  a  conical  stump;  it  like- 
wise prevents  the  adhesion  of  the  cicatrix 
Fig.  272.  ^Q  ^j^g  stump,  thereby  forming  the  basis 

for  a  movable  scar. 

If  the  patient  be  young,  new  bone  may  be  developed, 
which  lessens  the  sensibility  and  increases  the  usefulness 


AMPUTATING  INSTRUMENTS.  27I 

of  the  stump.  It  is  claimed  by  some  that  bony  spicula 
often  shoot  into  the  soft  tissues  on  the  end  of  the  stump, 
and  require  a  second  operation  for  their  removal.  It  is  my 
opinion,  however,  that  if  the  membrane  be  removed  entire 
and  in  connection  with  its  superimposed  tissues,  and  be  so 
placed  that  the  force  of  gravity  will  aid  in  holding  its  bone- 
producing  surface  in  cortact  with  the  divided  extremity, 
that  this  danger  will  be  obviated. 

Comparative  Me  fits  of  different  Forms,  of  Flaps. — The  ends 
sought  to  be  gained  in  making  flaps  are:  i.  To  secure  good 
drainage.  2.  To  make  them  of  suitable  length  that  the 
circulation  and  movement  of  the  cushion  at  the  end  may  be 
free.  3.  To  place  the  cicatrix  beyond  the  point  of  friction, 
and  prevent  its  adhesion  to  the  end  of  the  bone.  4.  To 
guard  against  any  danger  of  undue  sensibility,  by  making 
the  flaps  of  proper  length,  and  by  drawing  down  and  cutting 
off  the  cutaneous  and  other  nerves  of  larger  size  that  may 
exist  in  them.  With  these  ends  in  view,  it  will  be  seen  that 
the  old-fashioned  circular  flap  affords  equal  advantages 
with  the  others,  and  is  further  commended  by  its  simplic- 
ity. It  is  true  that  in  this  method  the  scar  will  fall  on  the 
end  of  the  stump,  but  with  proper  precautions  as  to  the 
length  of  the  flaps  and  suitable  attention  any  danger  from 
this  source  is  reduced  to  a  minimum. 

Agents  required  for  Amputation  may  be  classed  as  those 
for  arresting  hemorrhage  ;  for  the  division  and  trim- 
ming of  the  bone  and  soft  parts,  and,  those  for  uniting 
and  dressing  of  the  wound.  The  preparation  of  the  patient 
for  the  operation;  the  agents  for  controlling  and  arresting 
hemorrhage,  together  with  the  various  methods  of  securing 
and  maintaining  the  coaptation  of  the  cut  surfaces,  drain- 
age, and  various  forms  of  dressing,  antiseptic  and  other- 
wise, have  herein  been  previously  considered;  therefore, 
there  remains  to  be  enumerated,  under  this  heading  only 
those  instruments  especially  adapted  to  the  requirements 
of  the  procedure. 

Amputating  Knives  (Fig.  273). — The  modern  amputating 
knives  can  be  used  for  circular  flaps,  or  for  those  made  by 
transfixion.  They  should  be  double  edged  for  an  inch  or 
two  from  the  point.  The  length  selected  will  depend  upon 
the  size  of  the  limb  to  be  operated  upon,  and  should  be 
about  one  and  one  half  times  its  diameter.  It  may  be  in- 
consistent with  good  taste,  but  it  is  entirely  consistent  with 
good  judgment  and  economy  to  amputate  an  arm  or  fore- 


2/2 


OPERATIVE   SURGERY. 


arm  with  the  catling  intended  for  the  thigh,  and  the  result 
will  be  equally  satisfactory.  The  manner  of  holding  the 
catling,  prior  to  and  during  the  division  of  the  soft  parts, 
adds  much  to  the  optical  effect  of  the  operation.  It  should 
be,  at  first,  lightly  grasped  between  the  thumb  and  two 


Fig.  273. 


Fig.  274. 


first  fingers,  with  the  edge  forward,  near  enough  to  the 
shank  to  admit  the  upper  end  of  the  handle  to  play  between 
the  heads  of  the  metacarpal  bones  of  thumb  and  finger, 
when  it  is  swung  backward  and  forward  (Fig.  274).  There 
are  two  methods  employed  of  carrying  it  entirely  around 


METHOD   OF   USING  KNIFE.  273 

the  limb.  Stand  with  the  left  side  toward  the  patient, 
seize  the  limb  above  the  point  of  intended  operation  with 
the  left  hand,  an  assistant  holding  its  distal  extremity; 
place  the  left  foot  forward,  slightly  bend  the  right  knee, 
and  with  the  catling  held  by  the  right  hand,  as  before  de- 
scribed, stoop  downward  and  forward  sufficiently  to  carry 
the  knife  and  arm  under,  and  the  knife  over  the  limb,  plac- 
ing its  heel  as  near  to  the  upper  surface  of  the  limb  as  is 
convenient,  when,  with  a  sawing  motion,  it  is  drawn  to- 
ward the  operator  beneath  the  limb,  then  upward  between 
it  and  the  operator,  and  so  on  around,  until  it  joins  the 
beginning  of  the  cut,  making  a  complete  circle  (Fig.  275). 


Fig.  375.. 


If  the  knife  be  properly  grasped  it  will  pass  readily  be- 
tween the  thumb  and  forefinger,  as  the  hand  passes  around 
the  limb;  enabling  the  surgeon  to  make  the  section  with 
perfect  ease,  and  without  the  least  manifestation  of  the 
stiffness.  The  method  may  be  reversed  by  passing  the 
hand  and  knife  over,  instead  of  under  the  limb  (Fig.  276); 
otherwise  the  manipulations  are  the  same.  The  latter, 
however,  is  less  natural,  besides  which  it  exposes  the  arm 
of  the  operator,  and  the  integument  to  be  divided  last  to 
the  flow  of  blood.  Still  either  of  these  methods  is  far 
superior  to  the  one  commonly  employed  and  figured  in 
text-books  (Fig.  277). 


274 


OPERATIVE  SURGERY. 


Double-Edged Catliftg  {¥i^.  278). — This  is  chiefly  employed 
to  divide  the  tissues  in  the  interosseous  space,  in  amputa- 
tions of  the  leg  and  forearm.  It  can  be  readily  supple- 
mented by  the  single-edged  narrow  knife,  provided  the 
latter  be  withdrawn  to  complete  the  division  of  the  interos- 
seous tissues,  instead  of  changing  the  direction  of  the  cut- 
ting edge,  while  it  remains  between  the  bones.  The  latter 
act  will  bruise  and  tear  the  tissues.     To  these  should  be 


Fig.  376. 


added  two  or  three  ordinary  scalpels,  for  raising  integu- 
ment, flaps,  etc. 

A  knife  with  a  long  narrow  blade  is  the  better  for  am- 
putating at  the  phalangeal  articulations  (Fig.  279). 

Saws. — The  ordinary  broad  bladed  saw  (Fig.  280)  and 
the  bow-backed  (Fig.  281)  are  in  common  use.  The  first 
meets  all  requirements  except  in  certain  exsections,  when 
the  chain  or  butcher's  saw  (Fig.  282)  must  be  employed. 


AMPUTATING  INSTRUMENTS. 


275 


Fig.  277. 


Pig.  279. 


Fig.  280. 


Fig.  278. 


276 


OPERATIVE  SURGERY. 


The  narrow  movable  backed  saw  is  of  use  in  sawing  small 
bones,  removing  spiculae,  etc. 

The  proper  method  of  using  a  saw  should  be  given  some 
attention  (Fig.  283).     After  the  section  of  the  soft   parts, 


Fig.  281. 


Fig.  282. 


the  surgeon  grasps  the  saw  firmly,  places  its  heel  close  to 
the  edge  of  the  contracted  muscles,  in  a  line  made  through 
the  periosteum  b}'^  the  knife,  and  slowly  and  carefully  draws 
it  towards  himself  along  the  first  four  or  five  inches  of  its 
edge,  raises  it  from  the  track,  and  places  it  as  before;  re- 


METHOD   OF  USING  THE  SAW.  2^/ 

peating  the  operation  until  a  track  of  sufficient  depth  is 
made  to  retain  it  during  the  to-and-fro  movements  of  saw- 
ing, which  should  be  done  by  quick,  sharp  strokes,  until 


Fia  981, 

the  bone  is  neany  severed,  when  care  must  be  exercised,  or 
the  saw  will  be  clamped  and  the  remaining  portion  be  broken 
off.     If  the  handle  of  the  saw  be  raised  and  the  remaining 


278 


OPERATIVE   SURGERY. 


portion  be  divided  at  a  different  angle  to  the  bone,  the 
danger  of  breaking  is  lessened.  When  two  bones  are  to  be 
sawn  off,  the  saw  should  be  started  in  the  one  most  immov- 
able, and  then  turned  so  as  to  include  both.  If  the  movable 
one  clamp  the  saw,  cut  off  the  more  solid  one  first,  then 
complete  the  other. 


K'- 


Fig.  284. 


Fig.  285. 


Bone  Forceps. — Listen's  cutting  forceps  (see  Fig.  196)  for 
trimming  off  rough  prominences.  Ferguson's  lion-jawed 
(Fig.  284)  and  Farabeuf's  forceps  (Fig.  285)  are  excellent  in- 
struments for  grasping  the  bone  to  steady  the  part.  They 
are  also  used  for  removing  bone  by  twisting,  when  great 
force  is  required. 


HOW   TO   OPERATE. 


279 


How  to  Operate. — Before  beginning  an  amputation,  the 
operator  should  rehearse  in  his  mind  at  least  the  entire  pro- 
cedure as  lie  contemplates  it;  by  doing  this  he  will  be  con- 
fident, and  be  certain  to  anticipate  the  unimportant  as  well 
as  the  important  details.  The  preparation  of  the  patient 
and  administration  of  anaesthesia  are  given  on  pages  in  the 
fore  part  of  the  work.  The  surgeon  should  always  plan  his 
work  with  careful  precision,  even  to  marking  out  upon  the 
limb  the  outlines  of  the  flaps,  and  such  other  incisions  as 
may  be  required.     I  am  aware  that  this  is  seldom  practised, 


Fig.  286. 

even  by  the  most  experienced  surgeons;  but  within  my  own 
observations,  had  it  been  done  more  frequently  better  re- 
sults would  have  been  secured.  The  young  surgeon  too 
often  fancies  that  to  do  this  argues  himself  ignorant  and 
inexperienced;  such,  however,  is  not  always  the  case;  it 
rather  serves  to  empliasize  his  cautious  and  painstaking 
qualities.  All  operations  should  be  done  without  haste, 
when  the  safety  of  the  patient  will  permit;  remembering  it 
is  done  quickl}^,  when  done  well. 

The  operator  should  stand  in  such  a  relation  to  the  patient 
that  the  left  hand  can  readily  control  any  undue  hemor- 
rhage by  compressing  the  artery  or  otherwise. 


280 


OPERATIVE  SURGERY. 


The  primary  incision  should  be  so  located,  if  possible, 
that  the  escaping  blood  will  not  obscure  the  course  of  the 
remaining  ones. 

The  incision  which  will  divide  the  important  vessels 
should  be  made  last. 

In  circular  amputations  the  tissues  should  not  be  re- 
tracted until  after  the  division  of  the  integument. 

In  flaps  by  transfixion,  the  tissues  to  constitute  the  flap 
can  be  raised  or  depressed,  as  the  case  may  be. 


^^^;¥^sS5J,=SE|^^fiE^K&' 


Fig.  388. 


After  the  limb  is  removed,  the  open  mouths  of  the  ves- 
sels should  be  caught  by  serresfines,  forceps,  etc.  The  tour- 
niquet, or  Esmarch's  band  loosened  slowly,  and  all  bleeding 
points  controlled  in  a  like  manner  (Fig.  286).  The  sur- 
geon can  then  proceed  carefully  to  ligature  the  vessels  thus 
secured. 

The  retractor  is  made  of  linen,  or  ordinary  muslin,  torn 
according  to  the  size  and  anatomical  arrangement  of  the 
limb  to  which  it  is  to  be  applied.  If  to  one  with  two 
bones,  one  extremity  should  be  torn  into  three  strips  (Fig. 


HOW  TO   OPERATE. 


281 


Fig.  389. 


Fig. 


390. 


282  OPERATIVE   SURGERY. 

288).  The  middle  one  to  pass  between  the  bones  (Fig.  289). 
If  for  one  alone,  it  is  torn  partially  through  the  middle 
(Fig.  287),  and  applied  as  shown  in  Fig.  290. 


AMPUTATION    OF   UPPER   EXTREMITIES. 

General  Remarks. — In  all  amputations  of  the  hand  and 
fingers,  it  is  important  to  remember  that  usefulness  and 
symmetry  are  the  points  sought  to  be  gained.  If  strength 
and  usefulness  be  a  desideratum,  all  of  those  points  into 
which  the  muscles  and  ligaments  that  endow  the  part  with 
important  functions  are  inserted  should  be  preserved. 

It  therefore  becomes  imperative  for  the  surgeon  to  care- 
fully study  the  functions  of  the  muscles  associated  with  the 
hand;  and  to  preserve  as  carefully  as  possible  their  points 
of  insertion.  It  is  a  well-established  principle  that  every 
portion  of  the  hand  of  a  laboring  man  which  possesses 
movements  and  can  become  of  service  to  him  should  be 
saved.  In  the  case  of  one  whose  circumstances  or  avoca- 
tions will  permit  the  sacrifice  of  usefulness  to  symmetry, 
the  movements  may  be  sacrificed  with  the  concurrence  of 
the  patient. 


SPECIAL   AMPUTATIONS   OF   HAND  AND 
FINGERS. 

Amputation  at  the  Inter-Fhalangeal  Articulations. — The  first 
row  of  surgical  phalanges  is  flexed  by  the  terminal  insertion 
of  the  flexor  profundus  digitorum.  The  second  by  the  flexor 
sublimus  digitorum.  The  third  by  the  preceding,  through 
the  vincula  accessoria  tetidimifn ;  by  dense  fibrous  bands  con- 
necting the  tendons  of  the  flexor  sublimus,  with  the  distal 
extremity  of  that  phalanx  as  it  passes  across  it;  also  by  the 
secondary  action  of  the  lumbrical  muscles  (Fig.  291).  The 
terminal  phalanx  is  amputated  by  seizing  and  flexing  it  at 
right  angles  with  the  second  (Fig.  292);  a  transverse  incision 
is  then  made  on  its  dorsal  surface,  on  a  line  corresponding 
to    the  centre  of  the  long  axis  of  the   second    phalanx, 


AMPUTATION   OF   FINGERS. 


283 


which  will  open  the  joint;  divide  the  lateral  ligaments  with 
the  point  of  the  knife,  separate  the  articular  surfaces,  and 
pass  the  blade  between  them  along  the  under  surface  of 
the  phalanx  to  be  removed,  close  to  the  bone  (Fig.  293) 
far  enough  to  make  a  palmar  flap  of  sufficient  length  to 
easily  cover  the  end  of  the  bone  (Fig.  294).  If  the  attached 
extremity  of  the  flap  be  commenced  by  dividing  the  tissues 
at  each  side  of  the  phalanx  for  three  or  four  lines,  down  to 
the  bone,  the  knife  can  then  follow  its  under  surface  with- 


FiG.  991. — r.  Extensor  communis  digitorum.  2.  First  surgical  phalanx.  3.  Fi- 
brous bands  between  common  flexor  tendons  and  distal  extremity  of  the  third  surgical 
phalanx.  4.  Tendons  of  flexor  sublimus  digitorum.  5.  Tendon  of  fle.xor  profundus 
digitorum.  6.  Vincula  accessoria  tendinum.  7.  Head  of  metacarpal  bone.  8.  Joint 
between  second  and  third  surgical  phalanges,    g.  Second  surgical  phalanx. 

out  the  danger  of  making  the  attached  end  of  the  flap  too 
narrow,  owing  to  the  extremities  of  the  phalanges  being 
thicker  than  their  bodies.  The  rule  previously  given  re- 
garding the  length  of  flaps  will  ena  le  the  operator  to  meet 
this  requirement.  If  any  of  the  tissue  of  the  flexor  tendon 
be  in  the  flap,  it  should  be  removed.  T!e  the  vessels, 
place  and  hold  the  flap  in  position  by  two  or  three  fine 
sutures  and  adhesive  strips;  or  dress  antiseptically. 


284 


OPERATIVE   SURGERY. 


Amputation  of  the  Second  Row  can  be  done  in  precisely 
the  same  manner  as  at  the  first,  or  by  making  a  palmar-flap 
first  by  transfixion  with  the  finger  extended,  through  the 
palmar  surface  opposite  the  joint  and  cutting  downward 
until  a  well-rounded  flap  is  formed  (Fig.  295).  Then 
carry  the  knife  between  the  articular  surfaces  and  through 
the  soft  parts  on  the  dorsum  (Fig.  296). 


Fig.  292. 


Fig.  293. 


Fig.  294. 


Either  of  the  phalanges  may  be  amputated  at  the  centre, 
by  a  short  posterior  and  a  long  inferior  or  palmar  flap.  If 
the  third  surgical  (first  anatomical)  phalanges  be  ampu- 
tated at  the  centre,  the  power  of  flexion  is  limited  to  the 
lumbrical  muscle,  and  the  vincular  tendons  connecting  it 
with  the  flexor  sublimus  digitorum.  In  all  cases  where 
symmetry  is  a  subsidiary  consideration,   this  amputation 


Fig.  295. 


Fig.  296« 


may  be  made.  In  the  case  of  the  index  and  little  fingers, 
and  thumb,  everything  possible  adding  to  length  should 
be  saved,  as  the  range  of  motion  of  the  thumb  and  little 
finger  is  more  extensive  than  the  others,  and  the  presence 
of  the  index  or  its  stump  aids  the  crippled  thumb  in  per- 
formance of  its  functions. 

Amputation  at  the  Metacarpo-phalangeal  Articulations. — It  is 
recommended  by  some  that  this  operation  be  done  in  lieu 


AMPUTATION   OF   FINGERS. 


285 


of  amputation  at  the  middle  of  the  third  phalanges  (surgi- 
cal) of  the  second  and  third  fingers,  or  even  disarticulation 
between  their  second  and  third  phalanges.  I  am  satisfied, 
however,  that  the  hand  will  be  far  stronger  if  the  stumps  be 
allowed,  since  they  soon  become  easy  of  flexion  and  exten- 
sion, and  the  continuan-^e  of  these  movements  serves  to 
stimulate  and   nourish  the  common   muscles   engaged  in 


Fig.  297. 


them,  thereby  strengthening  the  power  of  the  remaining 
fingers. 

Amputation  of  the  Second  or  Third  Finger. — This  is  done  by 
the  oval  flap,  which  ought  to  be  marked  out  before  the 
operation  is  commenced  (Fig.  297).  The  flaps  must  be 
taken  from  the  finger  to  be  removed,  and  should  be  of 
generous  dimensions.  The  limit  of  the  incision  above 
corresponds   to   the  head    of    the    metacarpal   bone;    the 


286 


OPERATIVE   SURGERY. 


lower  limit,  to  the  transverse  line  joining  the  fingers  to 
the  web.  Separating  widely  the  contiguous  fingers,  the 
surgeon  seizing  the  condemned  finger,  extends  it  well  and 
carries  his  incision  transversely  along  the  line  beneath, 
then  in  a  curved  direction  upward,  along  the  side  of  the 
finger  to  the  head  of.  the  metacarpal  bone.  This  incision 
is  repeated  on  the  opposite  side;  the  tissue  carefully  dis- 
sected up,  ligaments  and  tendons  carefully  divided,  and 
the  finger  removed  (Fig.  298). 

Lateral  Flap  Operation. — This  is  best  adapted  to  the 
thumb,  index,  and  little  fingers  (Fig.299);  it  can,  however, 
be  employed  at  the  ring  and  middle  fingers.     The  limit  of 


Fig.  298. 


Fig.  299. 


the  incision  of  the  dorsum  is  the  same  as  in  the  preceding. 
The  lower  limit  after  crossing  the  transverse  line  of  the 
web  extends  towards  the  palm  about  a  third  of  an  inch. 
The  flaps  are  taken  from  the  sides  of  the  finger  to  be  re- 
moved. 

In  the  case  of  the  middle  and  ring  fingers  they  should  be 
equilateral.  For  the  thumb,  index,  and  little  finger,  that 
portion  of  each  against  which  pressure  is  most  liable  to  be 
brought  should  be  covered  by  a  longer  flap,  which  is  taken 
from  the  outer  surface  of  the  dorsum  of  the  index  and 
little  fingers  and  from  the  palmar  aspect  of  the  thumb,  the 
base  being  on  a  level  with  the  joint.     This  is  dissected  off. 


AMPUTATION   OF   FINGERS. 


287 


after  which  the  smaller  one  is  made;  divide  the  ligaments 
and  tendons,  and  remove  the  member. 

Amputation  of  the  Thumb  at  the  Carpo-metacarpal  Joint 
(oval  method,  Fig.  300). — This  can  be  employed  equally- 
well  upon  the  thumb,  index,  and  little  fingers.  The  limit  of 
the  dorsal  incision  in  either  instance  is  the  proximal  ex- 
tremity of  the  metacarpal  bone  to  be  removed.  Its  palmar 
limit  is  the  transverse  line  at  the  junction  of  the  finger  with 
the  palm.  Begin  the  first  incision  at  the  base  of  the  meta- 
carpal bone  of  the  thumb,  carrying  it  along  in  a  slightly 
curved  direction  to  the  outer  side  of  the  metacarpo- 
phalangeal articulation;  then  inward  through   the  line  of 


Fig.  300. 


Fig.  301. 


Fig.  302. 


the  web.  The  second  one  joins  the  first  near  the  base  of 
the  bone,  and  takes  a  corresponding  course  along  its  inner 
side,  meeting  the  former  at  the  inner  extremity  of  the  trans- 
verse line  of  the  web.  The  flaps  are  dissected  off,  and  the 
articulation  between  the  metacarpal  bone  and  the  tra- 
pezium is  opened  from  the  ulnar  side,  to  avoid  injuring  con- 
tiguous joints  (Fig.  301).  The  union  of  the  flaps  leaves  a 
linear  cicatrix  (Fig.  302). 

The  Lateral  Flap  Method  (Fig.  303). — This  method  can 
be  more  quickly  and  easily  performed  than  the  former,  but 
leaves  the  cicatrix  in  a  less  advantageous  situation.  Ab- 
duct the  thumb  and  enter  the  knife  between  the  first  and 


288 


OPERATIVE  SURGERY. 


second  metacarpal  bones;  carry  it  up  between  them  with 
a  sawing  motion,  till  the  head  of  the  first  is  reached.  Cau- 
tiously disarticulate  it  from  within  outward;  increase  the 
abduction,  and  carry  the  blade  through  the  joint  and  along 
the  outer  side  of  the  metacarpal  bone,  making  the  outer 
flap,  which  should  terminate  opposite  the  web  of  the  thumb 
(Fig.  304). 

The  description  of  the  oval  method  as  applied  to  the 
thumb  is  equally  applicable  to  the  index  and  little  fingers, 
if  an  interchange  of  digits  be  made.  The  lateral  flap 
method  is  not  advised  except  in  connection  with  the 
thumb. 


Fig.  303. 


Fig.  304. 


The  bases  oi  the  metacarpal  bones  of  the  index,  middle, 
and  little  fiyigers  should  be  preserved  in  all  possible  in- 
stances, as  they  afford  attachment  to  the  important  extensor 
and  flexor  muscles  of  the  carpus. 

Amputation  thi'ough  the  Metacarpal  Bones. — In  amputation 
through  two  or  more  of  these  bones,  the  principal  flap 
should  be  taken  from  the  palmar  surface.  If  but  one  be 
removed,  the  incisions  are  the  same  as  those  made  for  am- 
putation at  the  metacarpo-phalangeal  articulation  by  the 
oval  method,  only  their  upper  limit  will  correspond  to  the 
point  of  proposed  section  of  the  bone   (Fig.   305).     The 


AMPUTATION   OF   FINGERS. 


289 


bone  in  this  instance  is  to  be  sawn  through  with  a  chain  or 
metacarpal  bone  saw.  If  neither  of  these  be  convenient, 
the  cutting  bone  forceps  (Liston)  can  be  used,  although 
with  some  risk  of  splitting  the  bone.  This  operation  is 
often  performed  in  preference  to  disarticulation  at  its 
head,  in  order  to  give  symmetry  to  the  hand. 

The  division  of  the  transverse  ligament,  which  extends 
between  the  heads  of  the  metacarpal  bones,  lessens  the 
strength  of  the  grip.  This  operation  is,  therefore,  not  to 
be  recommended  except  in  those  of  sedentarj'  habits. 


Fig.  305. 


Amputation  {^Disarticulation)  of  the  Last  Four  Metacarpal 
Bones  (Fig.  306). — Make  a  semilunar  flap  from  the  palm 
by  a  curved  incision,  beginning  at  the  web  of  the  thumb  and 
terminating  at  the  ulnar  border  of  the  fifth  metatarsal  bone. 
This  flap  can  be  made  by  transfixion,  if  desired  (Fig.  307). 
The  dorsal  incision  (Fig.  30S)  begins  at  the  same  point  of 
the  web  of  the  thumb,  and  is  carried  to  the  upper  third  of 
the  metacarpal  bone  of  the  index  finger,  and  from  there 
transversely  across  until  it  meets  the  ulnar  extremity  of  the 
first  incision.     The  flaps  are  now  reflected  from  the  carpo- 


290 


OPERATIVE   SURGERY. 


metacarpal  joint,  the  hand  strongly  abducted,  and  the 
carpo-metacarpal  articulation  opened  from  the  ulnar  side, 
using  great  caution  not  to  injure  the  trapezium  and  the 


Fig.  306. 


Fig.  307. 


Fig.  308. 


Fig.  309. 


metacarpal  bone  of  the  thumb.     Without  the  thumb,  this 
operation  would   be   of   little   avail    in   securing  a  useful 


AMPUTATION   AT   WRIST. 


291 


Stump.  Unite  the  flaps  with  interrupted  sutures,  introduce 
a  drainage  tube  (Fig.  309),  and  treat  antiseptically.  The 
results  of  amputations  of  the  thumb  and  fingers  are  favor- 
able, three  to  six  per  cent  onl)?-  perishing. 

A7nputation  of  the  Wrist  [Disarticulation). — The  bones  en- 
tering directly  into  this  articulation  are  the  radius,  sca- 
phoid, and  semilunar.  Ine  location  of  the  joint  can  be  de- 
termined (i)  by  forcibly  bending  the  carpus  backward, 
when  the  summit  of  the  angle  on  the  dorsal  surface  formed 
by  the  hand  and  forearm  indicates  the  radio-carpal  joint ; 
(2)  by  drawing  a  line  transversely  from  one  styloid  process 


Fig.  3«». 

to  the  other — the  joint  is  about  one  fourth  of  an  inch  above 
it.  This  operation  can  be  done  by  the  circular  method, 
single  palmar,  or  radial  flap,  and  the  double  flap. 

Circular  Method. — Ascertain  one  fourth  of  the  circumfer- 
ence of  the  articulation.  Measure  this  distance  downward 
from  the  articulation,  and  divide  the  tissues  at  that  point 
by  a  circular  incision  ;  dissect  up  the  sleeve  of  integument 
until  opposite  the  joint ;  pronate  and  forcibly  flex  the  car- 
pus, and  open  the  wrist  joint  on  the  dorsal  surface  by  an 
incision  extending  between  the  styloid  processes  ;  divide 
the  lateral  ligaments,  pass  the  blade  through  the  articula- 


292 


OPERATIVE   SURGERY. 


tion,  and  sever  the  remaining  structures  (Fig.  310).  Unite 
the  flaps  in  the  long  axis  of  the  joint,  introduce  drainage 
tubes  and  sutures,  and  dress  antisepti- 
cally  (Fig.  311). 

Flap  Method  {Double). — Mark  out  the 
distal  limits  of  the  flaps  as  in  the  circu- 
lar method  ;  flex  and  pronate  the  hand  ; 
carry  a  semilunar  incision  over  its  dor- 
sum, beginning  at  the  styloid  process 
of  the  ulna  and  extending  to  the  circu- 
lar line  indicating  the  dorsal  extent  of 
the  flap,  terminating  at  the  radial  sty- 
loid process  (Fig.  312).  Dissect  up  the 
flap,  allowing  the  tendons  to  remain, 
flex  the  carpus  firmly,  and  open  the 
'"^'  ^"'  articulation,  as  in  the  circular  method  ; 

carry  the  blade  of  the  knife  through  the  articulation  (Fig, 
313)  and  make  the  anterior  flap  by  cutting  outward. 

Single  Palmar  Flap. — This  method  is  easily  performed, 


Fig.  312. 

and  makes  as  serviceable  stump  as  any.  Mark  out  a  flap 
on  the  palmar  surface,  semilunar  in  shape,  and  about  three 
and  a  half  inches   in  length,  its  base  being  located  just 


AMPUTATION  AT  WRIST.  293 

below  the  apices  of  the  styloid  processes  (Fig.  314)  ;  reflect 
it  upward  ;  divide  the  remaining  tissues  in  front  of  the  ar- 
ticulation, open  it,  passing  the  knife  through,  and  making 
a  short  dorsal  flap.  The  dorsal  flap  can  be  made  first, 
the  joint  opened  from  behind,  and  the  long  anterior  flap 
cut  from  the  joint  outwa'"d. 

Radial  Flap  (Dubrueil). — Mark  out  a  flap,  semilunar  in 
shape,  the  base  of  which  shall  embrace  the  radial  third  of 
the  carpus  and  the  ulna,  corresponding  to  the  base  of 
the  first  phalanx  of  the  thumb  (Fig.  315).  Separate  the 
thumb  flap,  then  connect  the  extremities  by  an  incision 
carried  transversely  around  the  ulnar  side,  draw  the  skin 
upward,  open  the  joint  as  before,  remove  the  carpus,  and 
properly  adjust  the  flaps  and  drainage  tubes  (Fig.  316). 


Fig.  313. 


The  rate  of  mortality  in  amputation  at  the  wrist  joint  is 
about  29  per  cent  for  gun-shot  wounds,  being  eight  per  cent 
greater  than  for  amputation  through  the  forearm. 

It  therefore  follows  that  amputation  at  the  wrist  joint 
cannot  be  recommended,  on  the  ground  of  safety  to  the 
patient.  There  are  other  objections  of  less  importance, 
which,  with  one  just  stated,  should  place  the  operation  in 
disfavor  with  the  surgeon.  It  makes  a  stump,  which,  owing 
to  the  feebleness  of  the  circulation  in  the  flaps,  becomes 
cold  and  even  chill-blained;  also  its  extremity  is  bulbous, 
thereby  preventing  the  application  of  properly  fitting  sock- 
ets connected  with  artificial  appliances. 


294 


OPERATIVE   SURGERY. 


Amputation  of  the  Forearm. — The  forearm  is  best  ampu- 
tated by  the  circular  flap  method;  although  the  equilateral 
skin  flap  and  musculo-cutaneous  are  often  employed. 

Circular  Amputation. — Carefully  lay  out  the  length  of  the 
proposed  flap,  based  on  a  fourth  of  the  circumference. 
Divide  the  tissues  down  to  the  fascia  surrounding  the  mus- 
cles by  a  circular  incision;  the  integumentary  cuff  is  then 
dissected  upward  by  repeated  incisions  directed  towards  the 
fascia  surrounding  the  muscles  (see  Fig.  26). 

If  the  cuff  be  too  small  to  turn  up  readily,  its  most  depend- 
ent part,  when  dressed,  can  be  slit  up.     After  the  flap  is 


^    ^ 


Fig.  315. 


Fig.  316. 


reflected  sufficiently,  the  muscles  are  divided  a  half  an  inch 
or  so  below  the  line  of  its  reflection  by  a  circular  sweep  of 
the  knife  down  to  the  bone,  the  bone  sawn  off,  and  the 
wound  dressed  in  the  usual  manner.  The  interosseous 
membrane  and  its  vessels  should  be  divided  a  short  dis- 
tance below  the  point  of  proposed  bone  section  and  its 
borders  be  separated  from  those  of  the  contiguous  bones 
up  to  where  they  are  to  be  sawn.  This  avoids  the  risk  of 
cutting  the  vessels  too  short,  as  when  they  are  divided  at  a 
level  with  the  bones  which  permits  them  to  retract  above 
the  point  of  easy  access.  These  remarks  apply  with  equal 
force  to  amputation  of  the  leg. 


AMPUTATION  AT  ELBOW. 


295 


The  equilateral  skin  flaps  are  raised  from  the  anterior  and 
posterior  or  internal  and  external  surfaces  ;  the  latter 
being  by  far  the  most  frequently  adopted.  The  length  is 
determined  in  the  same  manner  as  in  the  circular;  in  fact, 
if  the  circular  be  first  done,  and  its  angles  cut  off  down 
to  near  the  site  of  the  muscular  section,  the  lateral  flaps 
will  be  formed.  It  is  better,  however,  to  mark  out  their 
outlines  before  beginning  them;  since,  to  make  each  with 
the  same  curve  and  same  breadth  of  base  is  not  an  easy 


Fig.  317. 

task  without  this  precaution.  The  remaining  procedures 
are  the  same  as  those  of  the  circular  method. 

Miisculo-cutaneous  flaps  are  made  by  transfixion  and  cut- 
ting outward;  in  other  respects  the  steps  do  not  differ  from 
the  preceding  operation.  The  rate  of  mortality  in  ampu- 
tation of  the  forearm  is  about  21  per  cent  for  all  causes. 

A?nputatioji  at  the  Elbow  Joint  [Disarticulation). — The  meth- 
ods commonly  employed  are  the  circular  and  the  single  flap 
ones.    Before  operating  carefully  define  the  most  prominent 


296 


OPERATIVE  SURGERY. 


portions  of  the  condyles.  Just  below  the  outer,  is  felt  the 
movable  head  of  the  radius;  about  an  inch  below  the  inner, 
the  ulna  joins  the  inner  condyle;  the  articulation  is  there- 
fore oblique;  the  inner  portion  being  about  a  half  an  inch 
the  lower,  owing  to  the  inner  condyle  being  that  much 
longer  than  the  outer. 

Circular  Method. — Lay  out  the  flaps  in  the  usual  manner, 
measuring  around  the  condyles.  Divide  the  superficial  tis- 
sues down  to  the  fascia  surrounding  the  muscles,  as  before; 
dissect  the  flap  upward  to  a  level  with  the  joint,  the  bone 
indications  to  which  should  be  carefully  determined.     For- 


FlG.  318. 

cibly  extend  the  arm  and  make  an  incision  on  the  line  of 
the  articulation  (oblique)  down  to  and  into  it;  sever  the 
internal  and  external  lateral  ligaments,  and  press  the  arm 
still  further  backward,  and  draw  the  olecranon  process 
forward  into  the  wound,  and  sever  its  connection  to  the 
triceps  (Fig.  317).  Unite  the  borders  of  the  flap  as  indi- 
cated in  the  figure  (Fig.  318).  The  flaps  can  also  be  united 
from  before  backward;  this  causes  the  cicatrix  to  fall  between 
the  condyles,  and  likewise  increases  the  drainage  facilities 
— two  very  important  indications. 

The  shigle  fiap  fnethod  c2Sih&  made  either  of  integument 


AMPUTATION   OF  ARM. 


297 


and  subcutaneous  tissue  alone,  or  be  musculo-cutaneous; 
and  formed  by  transnxion.  In  either  instance  it  should  be 
taken  from  the  anterior  surface  of  the  forearm.  If  by- 
transfixion  (Fig.  319)  supinate  and  flex  the  forearm  slight- 
ly; raise  the  soft  parts  in  front  of  the  joint,  and  enter  the 
knife  an  inch  below  the  internal  condyle,  pass  it  in  front  of 
the  bones  obliquely  outward,  causing  it  to  escape  about 
one  and  one  half  inches  below  the  outer  condyle.  Cut  the 
anterior  flap  downward  and  outward,  making  it  about 
three  and  one  half  inches  in  length;  dissect  and  draw  the 
flap  up  to  a  level  with  the  joint  in  front.  Make  the  poste- 
rior flap  by  connecting  the  extremities  of  the  first  incision 
by  a  transverse  one  (Fig.  320),  and  dissect  this  up,  after 


Fig.  319. 


Fig.  390, 


which  the  joint  is  opened  from  in  front;  the  lateral  ligaments 
divided,  olecranon  process  displaced  forward,  and  the  tri- 
ceps cut  off.  It  is  advisable,  when  possible,  to  saw  off  the 
olecranon,  allowing  it  to  remain  with  the  triceps  attached. 
The  stump  will  be  stronger  if  it  be  possible  to  sever  the 
ulna  below  the  insertion  of  the  brachialis  anticus,  allowing 
the  fragment  to  remain  along  with  its  muscular  attach- 
ments. In  amputations  near  the  elbow,  the  tubercle  of  the 
radius,  along  with  the  biceps  tendon  inserted  into  it,  should 
be  carefully  preserved.  The  deaths  from  this  amputation 
vary  from  17  to  30  per  cent.  In  the  latter  rate,  the  opera- 
tion was  done  for  gunshot  injuries. 

Amputation  of  the  Arm. — Either  the  circular,  double  flap, 
or  the  single  circular  incision  method  can  be  employed. 
The  former  is  usually  preferred.     In   the  second   the   flap 


298  OPERATIVE  SURGERY. 

may  be  anterior,  posterior,  or  lateral;  integumentary  alone, 
or  combined  with  muscular  tissue.  The  single  circular 
operation  is  seldom  employed. 

Circular  Flap. — Plan  the  length  of  the  flap  upon  the  cir- 


FlG.  321. 

cumference  of  the  limb  at  the  point  of  proposed  section. 
Divide  the  superficial  tissues  down  to  the  muscular  fascia, 
and  turn  the  flap  up  as  elsewhere;  then  divide  the  muscles 
down  to  the  bone,  about  one   inch  below  the  reflection  of 


AMPUTATION  OF  ARM.  299 

the  flaps.  Apply  the  two  tailed  retractor,  saw  off  the  bone, 
and  unite  the  flaps  in  the  direction  best  calculated  to  pro- 
vide dependent  drainage. 

Double  Flap  Method. — If  skin  alone  be  used  the  flaps 
should  be  carefully  mapped  out  upon  the  integument  of 
the  arm,  in  the  general  manner  before  described.     Dissect 


Fig.  3!W 

them  up  and  make  a  circular  section  of  the  muscles  down 
to  the  bone;  unite  the  flaps,  and  dress  the  stump  as  before. 
Jf  musculo-ctttaneous  Jlap  {l^dingtnbtck)  be  desired,  they  can 
be  made  from  within  outward  by  transfixion,  or  from  with- 
out inward,  with  a  scalpel.  The  latter  plan  secures  the 
more  uniformity  of  outline  in  the  flap.  If  they  are  to  be 
made  from  without  inward,  first  mark  them  out  carefully, 


300 


OPERATIVE   SURGERY. 


then  with  a  sharp  scalpel  form  them  as  planned  (Fig. 
321);  when  dissected  up  the  desired  distance,  complete  the 
operation  by  dividing  the  muscles  as  before. 

Large  anterior  and  small  posterior  skin  flaps  are  some- 
times made  (Fig.  322),  also  a  large  anterior  one,  with 
a  posterior  circular  incision  (Fig.  323).     They  possess  the 


Fig.  393. 

advantage  of  good  drainage,  and  placing  the  cicatrix  where 
it  is  well  removed  from  irritation.  The  outline  of  these  flaps 
can  be  easily  estimated  on  the  same  basis  as  if  they  were 
to  be  equal  in  length,  viz.,  if  one  be  proportionately  in- 
creased in  length,  the  other  is  to  be  shortened.  The  death 
rate  from  amputation  of  the  arm  is  over  27  per  cent.  Be- 
ing greater  than  for  excision  of  the  elbow  joint. 

Amputation  at  the  Shoulder  Joint  {JDisarticulatiofi) . — There 
are  various  methods  recommended  for  amputation  at  this 


AMPUTATION   AT   SHOULDER. 


301 


Fig.  334. 


302 


OPERATIVE   SURGERY. 


joint.  It  is  hardly  necessary  to  enter  into  the  details  of 
more  than  two  or  three  of  those  commonly  recognized  and 
employed.  The  remainder,  while  ingenious  in  many  in- 
stances, do  not  present  differences  of  enough  practical 
worth  to  be  introduced  into  a  hand-book  of  operative 
surgery. 

Amputation  by  Internal  and  External  Flaps. — Place  the  pa- 
tient on  the  edge  of  the  table,  partially  upon  the  healthy 
side,  with  the  body  raised.  An  external  oval  flap  is  made 
by  an  incision  extending  from  the  coracoid  process  down- 


Fig.  3S5. 

ward  and  outward  to  the  insertion  of  the  deltoid;  then 
upward  and  backward,  terminating  at  the  junction  of  the 
acromion  process  with  the  spine  of  the  scapula  (Fig.  324). 
The  flap  including  the  deltoid  muscle  is  now  raised  as  far 
as  the  acromion,  turned  back,  and  the  capsule  of  the  joint 
exposed,  the  head  of  the  humerus  pushed  upward,  capsule 
divided  above;  then  the  arm  is  rotated  outward  and  the 
subscapularis  severed,  followed  by  the  rapid  division  of 
the  external  rotators  attached  to  the  greater  tuberosity. 
While  the  arm  is  rotated  internally,  the  capsule  is  still 
further  divided,  along  with  the    tendon  of  the  long  head 


AMPUTATION  AT  SHOULDER. 


303 


of  the  biceps,  the  head  ofr  the  humerus  tilted  outward,  and 
the  blade  of  the  knife  passed  beneath  it  (Fig.  325),  the  head 
of  the  humerus  seized  and  drawn  outward,  and  the  knife 
carried  along  its  inner  surface  until  within  about  four 
inches  below  the  axillary  fold,  when  its  edge  is  turned  in- 
ward and  the  flap  completed.  The  last  sweep  of  the  knife 
severs  the  principal  vessels,  and  this  flap  should  be  seized 
by  an  assistant  and  tightly  grasped  before  it  is  completed. 
The  vessels  in  this  operation  are  controlled  by  either  press- 
ure upon  the  third  portion  of  the  subclavian,  or  by  the  elas- 


FiG.  336. 


tic  band  arranged  as  shown  in  the  illustration.  The  appear- 
ance of  the  wound  after  the  operation  is  shown  in  Fig.  326. 
Amputation  by  Circular  Incision. — Control  the  circulation  as 
before.  Abduct  the  arm  and  make  a  circular  incision  en- 
tirely around  it  through  all  the  tissues,  down  to  the  bone, 
at  a  point  corresponding  to  the  insertion  of  the  deltoid. 
Saw  off  the  bone  and  ligature  the  vessels.  Make  a  second 
incision  longitudinally,  from  the  anterior  border  of  the 
acromion,  the  whole  length  of  the  stump,  down  to  the  bone. 
The  bone  is  then  held   firmly  and  the  soft  parts  separated 


304 


OPERATIVE   SURGERY. 


from  it  (Fig.  327),  after  which  it  is  rotated  outward,  then 
inward  to  admit  of  the  division  of  the  muscular  and  fibrous 
attachments  to  its  head,  when  it  can  be  removed.  This 
is  a  good  operation  and  well  calculated  to  provide  favor- 
able drainage  (Fig.  328),  and  is  done  with  a  minimum 
amount  of  injury  to  the  soft  parts. 


Fig.  327. 

Oval  Method  i^zxtty). — This  method  is  well  thought  of, 
and  is  performed  by  making  a  vertical  incision  from  the 
extremity  of  the  acromion  process,  with  the  arm  extended, 
about  three  inches  in  length  down  to  the  bone;  this  inci- 
sion should  terminate  about  one  inch  below  the  head  of  the 
humerus.     Two  oblique  incisions  are  then  made,  starting 


AMPUTATION  AT   SHOULDER. 


305 


near  the  middle  of  the  vertical  cut,  one  on  the  anterior  and 
the  other  on  the  posterior  aspect  of  the  limb;  which,  when 
carried  through  the  structures  composing  the  anterior  and 
posterior  walls  of  the  axilla,  to  the  lower  border  of  each, 
divides  their  attachments  to  the  humerus  (Fig.  329).  The 
soft  parts  on  the  inner  side  of  the  humerus  still  remain 
undivided.     The  lips  of  the  wound  are  now  drawn  apart, 


Fig.  328. 


the  joint  exposed  and  opened  above;  the  bone  drawn  down- 
ward to  separate  the  joint  surfaces,  and  the  blade  of  the 
knife  passed  between  them,  behind  the  luxated  bone,  and 
the  operation  completed  by  cutting  the  remaining  tissues 
at  the  inner  side  of  the  humerus  intervening  between  the 
lower  extremities  of  the  incisions  previously  made  (Fig. 
330). 


3o6 


OPERATIVE   SURGERY. 


Spence's Method  \\^as  attracted  some  considerable  attention, 
and  is  certainly  entitled  to  additional  consideration. 

It  does  not  possess  any  advantages  over  the  method  by 
single  circular  incision.     It  is  done  in  the  following  man- 


FlG.  329. 


Fig. 


ner:  Abduct  the  arm  slightly;  rotate  the  humerus  out- 
ward; cut  down  upon  the  head,  beginning  immediately 
external  to  the  coracoid  process,  thence  directly  down- 
ward through  the  fibres  of  the  deltoid  and  pectoralis  major 
to  the  lower  border  of  the  latter,  which 
is  divided;  carry  the  incision  with  a 
gentle  curve  across  and  through  the 
lower  fibres  of  the  deltoid,  to,  but  not 
through,  the  posterior  border  of  the 
axilla  (Fig.  331).  Begin  the  inner 
incision  at  the  lower  extremity  of  the 
vertical  one,  carry  it  around  the  inner 
side  of  the  arm,  through  the  skin  and 
fat  only,  to  meet  the  one  made  at  the 
outer  side.  If  the  fibres  of  the  del- 
toid have  been  thoroughly  divided,  the 
flap,  together  with  the  posterior  circum- 
flex artery  can  be  easily  separated  by 
the  finger,  from  the  bone  and  joint, 
drawn  upward  and  backward  until  the 
Fig.  331.  head  of  the  bone  is  exposed;  when  the 

ligaments   and    muscular    attachments   are   divided,   and 


AMPUTATION  ABOVE   SHOULDLxv.  307 

disarticulation  accomplished,  the  remaining  soft  parts  at 
the  axillary  aspect  are  divided. 

In  very  muscular  subjects,  a  redundancy  of  that  tissue 
in  the  flap  can  be  avoided  by  dissecting  upward,  a  short 
distance,  the  integument  and  subcutaneous  tissues  over  the 
deltoid,  and  dividing  its  fibres  high  up. 

The  rate  of  mortality  varies  from  37  to  nearly  50  per 
cent. 

Amputation  above  the  Shoulder  Joint. — It  may  become  nec- 
essary on  account  of  malignant  growths  to  amputate  the 
scapula  along  with  a  portion  or  the  whole  of  the  clavicle. 

The  operation  is  often  tedious  and  attended  with  great 
loss  of  blood.  Inasmuch  as  the  situation  of  the  disease  or 
injury  calling  for  it  will  modify  the  location  and  direction 
of  the  incisions,  no  definite  plan  can  be  prescribed.  How- 
ever, the  aim  should  be  to  always  save  enough  healthy  in- 
tegument to  cover  the  wound  and  to  avoid  hemorrhage. 

Fifty-one  cases  are  reported,  with  a  mortality  of  25.5  per 
cent. 


Manual  of  nDP,;,fn,p"^,,^-'  '•' 


2002129957 


:  I 


'  1  ■      ' 


